HX641 20635 
RC71.B791914      Diagnostic  methods, 


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DIAGNOSTIC    METHODS 


DIAGNOSTIC  METHODS 


A  Guide  for  History  Taking,  Making  of  Routine 

Physical   Examinations   and    the   Usual 

Laboratory   Tests   Necessary   for 

Students  in  Clinical  Pathology, 

Hospital    Internes,    and 

Practicing  Physicians 


By 
HERBERT  THOMAS  BROOKS,  A.B.,  M.D., 

Professor   of    Pathology,    University   of    Tennessee,    College    of    Medicine, 
Memphis,  Tennessee 


SECOND  EDITION 

Revised  and  Revjritten 


ST.   LOUIS 
C.  V.   MOSBY  company 

1914 


Copyright,  1914,  By  C.  V.  Mosby  Company 


Press  of 

C.  V.  Mosby  Company 

St.  Louis 


PREFACE  TO  SECOND  EDITION 


This  little  book  is  intended  for  medical  students,  hospital 
internes  and  physicians  who  have  a  limited  amount  of  time 
to  give  to  laboratory  work. 

Every  possible  care  has  been  used  to  incorporate  in  this 
guide  only  the  up-to-date  and  absolutely  reliable  laboratory 
tests.  If  one  is  able  to  perform  these  tests  accurately  and  at 
the  same  time  place  the  proper  interpretation  on  the  results, 
he  will  be  very  materially  assisted  in  coming  to  an  accurate 
diagnosis. 

H.  T.  B. 

Memphis,  Tenn., 
January,  1914. 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diagnosticmethodOObroo 


CONTENTS 


Chapter  I.  Pages 

Outline  for  History  Taking 9-12 

Chapter  II. 
Pliysical  Examination  of  the  Patient 13-18 

Chapter  III. 
Sputum    19-24 

Chapter  IV. 
Urine ,     25-37 

Chapter  V. 
Gastric  Contents  38-44 

Chapter  VI. 
Blood  - 45-53 

Chapter  VII. 
Serous  Fluids    54-57 

Chapter  VIII. 
Intestinal  Contents 58-63 

Chapter  IX. 
Tuberculin  Diagnosis    64-66 

Chapter  X. 
The  Wassermann  Reaction   67-71 

Chapter  XI. 
Complement  Fixation  Test  for  Gonorrhea 72-73 

Chapter  XII. 

Apparatus  and  Chemical  Reagents  Necessary  for  a  Physician's 

Laboratory 74-76 


DIAGNOSTIC   METHODS 


CHAPTEE  I. 
OUTLINE  FOR  HISTORY  TAKING. 

Obtain  from  the  patient  the  following : 

1.  Name.  5.  Address, 

2.  Age.  6.  Weight. 

3.  Occupation.  7.  Height. 

4.  Social  Relation.  8.  Color. 

Chief  Complaint  and  Duration  of  Symptoms. 

Secure  from  patient  in  as  few  words  as  possible  the  thing 
or  things  that  give  him  the  most  trouble.  Get  date  of  begin- 
ning and  duration  of  each. 

Family  History. 

If  living,  the  health  of,  or  if  dead  the  cause  and  age  of 
death  of  father,  mother,  brothers,  sisters,  uncles  and  aunts. 
Secure  positive  or  negative  history  of  tuberculosis,  cancer, 
rheumatism,  gout,  diabetes. 

Personal  History. 

Get  the  habits  of  the  patient  as  to  the  use  of  alcohol,  to- 
bacco and  drugs ;  habits  as  to  sleep  ;  exact  nature  of  past  and 
present    occupations ;    condition    of    present    surroundings, 

(9) 


10  Diagnostic  MetJiods. 

whether  sanitary  or  not.     If  the  patient  is  a  woman  obtain 
the  following: 

Menstrual  History. — Age  of  commencement;  regularity; 
duration;  quantity,  whether  copious  or  scanty,  associated 
with  pain  ( ? )  ;  date  of  last  menstruation ;  presence  of  leucor- 
rhea. 

Obstetrical  History. — ^Number  of  children,  age  of 
youngest,  number  of  miscarriages,  date  of  last,  character  of 
labor,  complications  occurring  during  labor  or  immediately 
following. 

Past  History. 

Diseases  of  childhood,  especially  acute  rheumatism,  scar- 
latina, diphtheria,  or  tonsillitis.  All  other  diseases  or  inju- 
ries prior  to  this  illness.  Ask  your  patient  if  he  has  had  syph- 
ilis, or  if  he  has  been  exposed  to  same.  Also  ask  if  he  has  had 
gonorrhea  or  a  sore  of  any  kind.  Any  acute  infection  as 
typhoid  or  pneumonia? 

History  of  the  Present  Illness. 

Chief  complaint,  date  of  beginning ;  onset,  slow  or  sudden ; 
order  of  appearance  of  symptoms,  which  gave  patient  the 
most  trouble ;  character  of  treatment  if  any.    ' 

Alimentary  Canal. — 

If  symptoms  indicate  disease  of  the  alimentary  canal,  ask 
the  following  questions:  (a)  Appetite;  (b)  Meals — nature 
of  the  food  patient  most  craves;  (e)  Sensations  referred  to 
the  stomach — pain,  fullness,  or  discomfort.  Give  location  of 
pain  and  radiation  if  any;  (d)  Vomiting — time  of  day,  rela- 
tion to  food,  relieves  pain  or  not,  any  retching;  (e)  Charac- 
ter of  vomited  material — amount,  color,  red,  coffee  grounds, 
sour  or  frothy  ;  (f)  Eructations  of  gas ;  (g)  Flatulence — rela- 
tion to  what  particular  kind  of  food,  and  does  the  gas  tend 
to  go  up  or  down;  (h)  State  of,  the  bowels — as  the  presence 
of  diarrhoea — is  it  associated  with  blood,  slime  or  tenesmus, 
does  any  particular  kind  of  food  appear  to  bring  it  on?  (i) 
Constipation — usual  habits  as  to  bowel  movement;  (j)  Pain 
in  the  abdomen — where  is  it  the  worst,   is  it  persistent   or 


Outline  for  History  Taking.  11 

intermittent,  is  it  relieved  or  made  worse  by  pressure?     Is 
there  any  radiation,  any  soreness  following? 

Liver. — 

If  symptoms  indicate  the  trouble  to  be  in  the  liver,  the  fol- 
lowing questions  are  to  be  asked:  (a)  Pain  —  any  severe 
pain  coming  on  and  lasting  a  few  hours  only.  Was  the  pain 
associated  with  vomiting?  Does  it  radiate?  Any  pain  in  the 
shoulder?  Was  the  patient  yellow  after  the  attack?  (b) 
Piles;  (c)  Vomiting  of  blood;  (d)  Any  change  in  the  color 
of  urine  or  feces;  (e)  Inquire  as  to  the  presence  of  digestive 
disturbances. 

Cardiovascular  System. — 

If  the  symptoms  indicate  that  the  trouble  is  in  the  cardio- 
vascular system,  the  following  questions  should  be  asked:  (a) 
Any  dyspnoea;  (b)  Precordial  pain  or  discomfort — does  it 
radiate;  (c)  Any  palpitation — relation  to  meals  and  exer- 
tion? (d)  Headache;  (e)  Giddiness;  (f)  Sleep;  (g)  Any 
cough;  (h)  Presence  of  digestive  disturbances;  (i)  Swelling 
of  feet;  (j)  Presence  of  nose  bleeding? 

Respiratory  System. — 

If  the  symptoms  indicate  that  the  trouble  is  in  the  respira- 
tory system,  the  following  questions  should  be  asked:  (a) 
Any  cough — character  of  cough,  when  worse,  any  pain,  as- 
sociated with  vomiting;  (b)  Expectoration — ^yellow  or  not, 
any  blood  present  and  how  much,  and  whether  only  after 
severe  coughing;  (c)  Any  pain  in  chest — pain  on  deep  breath- 
ing and  where  situated;  (d)  Dyspnoea — is  it  spasmodic,  and 
describe  the  attack  if  it  is;  (e)  Night  sweats;  (f)  Loss  of 
weight;   (g)   Loss  of  strength;   (h)   Fever;   (i)   Hoarseness. 

Kidneys. — 

If  the  symptoms  indicate  that  the  trouble  is  in  the  kidneys, 
the  following  questions  should  be  asked:  (a)  Any  headache; 
(b)  Drowsiness;  (c)  Dimness  of  vision;  (d)  Attacks  of 
dyspnoea;  (e)  Vomiting;  (f)  Paralysis;  (g)  Convulsions; 
(h)  Does  the  face  look  puffy  in  the  morning;  (i)  Any  swell- 
ing in  the  ankles;    (j)    Urine — altered  in  amount,   clear  or 


12  Diagnostic  Methods. 

turbid,  any  blood,  and  is  it  present  at  the  early  or  the  latter 
part  of  urination;  (k)  Does  the  patient  have  to  rise  in  the 
night  to  pass  urine;  (1)  Is  there  any  increase  in  frequency 
and  is  this  by  day  or  by  night;  (m)  Pain  on  micturition? 
(n)  Pain  in  lumbar  region — does  it  radiate  to  the  groin. 

Nervous  System. — 

If  the  symptoms  indicate  that  the  trouble  is  in  the  nervous 
system,  the  following  questions  may  be  asked:  (a)  Any 
headache  (when  worse,  where  located,  character  of  the  head- 
ache) ;  (b)  Nausea  or  vomiting ;  (c)  Dizziness;  (d)  Difficulty 
in  walking;  (e)  Any  transient  palsies,  or  transient  loss  of 
memory;  (f)  Any  visual  disturbances ;  (g)  Convulsions  (gen- 
eral or  local,  age  of  beginning,  frequency,  any  premonition, 
bite  tongue,  micturate  or  defecate)  ;  (h)  Any  discharge  from 
ear  at  any  time. 

Blood.— 

If  the  symptoms  indicate  that  the  trouble  is  in  the  blood, 
the  following  questions  should  be  asked:  (a)  Any  dyspnoea? 
(b)  Headache;  (c)  Dizziness;  (d)  Swelling  of  feet;  (e)  Pre- 
vious attacks. 

Bones  and  Joints. — 

If  the  symptoms  indicate  that  the  trouble  is  in  the  bones 
or  the  joints,  the  following  questions  may  be  asked :  (a)  Pain 
in  bone — worse  day  or  night;  (b)  Pain  in  joint — constantly 
present  or  only  when  the  joint  is  moved;  (c)  Any  sudden 
starting  pains  at  night;  (e)  Is  the  pain  affected  by  the 
weather;  (f)  Does  the  pain  shift  from  one  joint  to  the  other. 

Child.— 

If  the  patient  is  a  child,  the  following  questions  should  be 
put  to  the  mother:  (a)  Number  of  children;  (b)  Any  dead 
and  the  cause;  (c)  Any  miscarriages;  (d)  Mother's  health 
during  pregnancy;  (e)  Is  it  a  full  time  child;  (f)  Was  the 
labor  normal;  (g)  Was  the  child  breast  fed;  (h)  What  food 
is  being  given  the  child  at  the  present  time;  (i)  Was  there 
any  rash  or  snuffles  after  birth;  (j)  State  the  age  of  cutting 
of  teeth  and  walking;  (k)  Give  the  usual  condition  of  the 
child's  bowels;  (1)  Any  bronchitis,  measles,  whooping  cough, 
chicken  pox,  scarlatina,  discharge  from  the  ears. 


CHAPTER   II. 
PHYSICAL   EXAMINATION   OF   THE   PATIENT. 

General  Survey  of  the  Patient. 

Note  the  following:  (a)  Nutrition;  (b)  Attitude;  charac- 
teristic of  any  trouble;  (c)  Expression,  whether  animated, 
apathetic  or  placid;  (d)  Complexion;  (e)  Eruptions;  (f) 
Enlargement  of  lymph  nodes  or  presence  of  any  tumor 
masses;    (g)   Deformities,  either  congenital  or  acquired. 

Examination  of  the  Alimentary  Canal  and  the  Abdomen. 

Examine. — 

(a)  Lips.' — ^Noting  the  presence  of  cyanosis,  anaemia, 
herpes,  or  fissures;  (b)  Teeth. — Note  the  presence  of  caries, 
exposures  of  roots,  pyorrhea,  or  congenital  syphilis;  (c) 
ToisTGUE. — Note  the  presence  of  tremor,  any  deviation  on  pro- 
trusion, size,  papillse,  coating  (moist  or  dry)  ;  (d)  Palate, 
Fauces,  and  Pharynx. — Note  the  presence  of  ulcers,  mucous 
patches,  enlarged  tonsils,  white  patches  on  tonsils  or  uvula 
or  soft  palate;  (e)  Esophagus. — ^Any  difficulty  in  swallow- 
ing, if  necessary  pass  the  stomach  tube,  and  note  presence  of 
pain,  stricture  or  diverticulum ;  (f)  Abdomen.— Inspection. — 
Note  general  contour,  the  presence  of  pulsations  in  epigas- 
trium, movements  of  abdominal  wall,  peristaltic  waves,  pres- 
ence of  stride,  pigmentations,  or  scars;  Palpatio^i. — Examine 
for  the  presence  of  tenderness,  tumor,  rigidity  of  muscles, 
and  gurgling;  Percussion. — ^Examine  for  dullness  in  the 
flanks,  if  present  is  it  movable,  presence  of  free  gas  in  the 
peritoneal  cavity;  (g)  Stomach. — Inspection. — Examine  for 
the  presence  of  visible  tumors,  dilatations,  and  peristaltic 
waves;  Palpation. — Examine  for  tenderness,  tumors,  and 
splashing;  Percussion. — Examine  for  position  of  greater 
curvature,  lower  border  of  liver  and  lung.  Inflate  the  stom- 
ach and  examine  for  size  and  position. 

(13) 


14  Diagnosiic  Methods. 

Liver. — Inspection. — Look  for  the  edge  of  the  liver  and 
the  presence  of  pulsations.  Palpation. — Examine  for  tender- 
ness, position  of  the  lovrer  border,  regularity  or  irregularity 
of  surface.  Percussion. — Examine  for  upper  border  of  dull- 
ness in  the  mid-clavicular  line,  mid-axillary  line  and  scapula 
line. 

Spleen. — Note  whether  or  not  palpable,  position  of  the 
lower  pole. 

Kidneys. — Note  whether  or  not  palpable,  presence  of  ten- 
derness, and  extent  of  mobility. 

Examination  of  the  Cardiovascular  System. 

Heart. — Inspection.' — Note  the  shape  of  the  praecordial  re- 
gion, presence  of  pulsation — normal  and  abnormal  in  the 
precordial  region  and  immediately  beyond,  as  in  episternal 
notch,  neck,  to  right  of  sternum,  and  epigastrium. 

Palpation. — ^Location  and  description  of  apex  beat,  pres- 
ence and  location  of  thrills,  and  whether  systolic,  diastolic, 
or  presystolic.  Note  the  presence  of  a  friction  rub,  and  any 
abnormal  pulsations. 

Percussion. — Outline  of  superficial  and  deep  cardiac  dull- 
ness; description  of  any  abnormal  areas  of  dullness. 

Auscultation. — Relative  intensity  of  heart  sounds  in  va- 
rious valvular  areas.  Note  the  presence  and  give  description 
of  adventitious  sounds,  as  cardiac  murmurs,  vascular  mur- 
murs, and  pericardial  friction  rub. 

Pulse. — Note  the  presence  of  arteriosclerosis;  approxi- 
mate blood  pressure,  whether  low,  moderate  or  high;  char- 
acter and  quality  of  the  pulse,  especially  whether  character- 
istic of  aortic  insufficiency  or  stenosis.  Note  the  presence  or 
absence  of  venous  pulsation  in  the  neck. 

Examination  of  the  Respiratory  System. 

Thorax. — Inspection. — Note  the  shape  whether  symmet- 
rical or  the  presence  of  unilateral  depressions  or  fullness. 
Note  the  presence  of  alar  chest,  flat  chest,  emphysematous 


Physical  Examination  of  the  Patient.  15 

chest,  rachitic  rosary,  pigeon  breast,  Harrison's  sulcus. 
Note  intercostal  spaces  for  undue  fullness  or  retraction.  Note 
the  respiratory  movements  as  to  rate,  type,  equality  or  in- 
equality of  expansion.  Note  the  presence  of  Litten's  dia- 
phragmatic sign. 

Palpation. — Examine  the  respiratory  movements  as  to 
equality  or  inequality  of  expansion.  Note  any  localized  de- 
ficiency of  expansion.  Note  the  presence  and  location  of 
friction  fremitus.  Examine  the  vocal  fremitus  as  compared 
with  the  normal. 

Percussion. — Compare  the  corresponding  areas  of  the 
chest.  Outline  the  apices,  lower  borders  of  both  lungs,  and 
note  whether  the  resonance  is  normal,  diminished,  or  in- 
creased. Note  the  presence  and  location  of  any  abnormal 
areas  of  dullness. 

Auscultation. — Note  the  character  of  the  breath  sounds, 
whether  normal,  increased,  diminished  or  absent.  Note  the 
presence  and  location  of  any  abnormal  areas  of  tubular, 
broncho-vesicular,  cogwheel,  or  other  abnormal  types  of 
breathing.  Note  the  presence  of  any  adventitious  sounds,  as 
rales  (dry,  bubbling,  crepitant,  or  sub-crepitant).  Also  note 
pleuritic  friction  sounds.  Note  vocal  resonance,  whether 
normal,  increased,  diminished  or  absent. 

Examination  of  the  Nervous  System. 

Cranial  Nerves. — 

Olfactory  Nerves. — Use  oil  of  cloves,  oil  of  peppermint 
or  asafoetida.     Compare  the  sense  of  smell  in  both  nerves. 

Optic  Nerves. — Test  the  acuteness  of  vision,  extent  of 
visual  fields  in  both  eyes. 

Motor  Oculi,  Troclear,  and  Abducent  Nerves. — Note 
the  presence  of  strabismus,  or  ptosis.  Test  for  defects  in 
ocular  movements,  for  diplopia,  and  for  nystagmus.  Note 
the  size  and  shape  of  pupils.  Test  their  reaction  to  light 
and  accommodation. 

Trifacial  Nerves. — Test  the  motor  functions  by  having 
the  patient  clinch  the  teeth  tightly,  and  feel  the  contractions 


16  Diagnostic  Methods. 

of  masseter  and  temporal  muscles.  Test  the  sensory  func- 
tions. 

Facial  Nerves. — Close  the  eyes  tightly,  wrinkle  the  fore- 
head, and  elevate  the  upper  lip,  noting  any  lack  of  symmet- 
rical muscular  action. 

Auditory  Nerves. — Test  acuteness  of  hearing  on  both 
sides  with  watch.     Examine  for  the  presence  of  vertigo. 

Glossopharyngeal  Nerves. — Examine  for  taste  on  the 
posterior  surface  of  the  tongue  by  using  a  little  sugar  or 
quinine.  Tickle  the  pharynx  and  note  the  presence  of  any 
gagging. 

Vagus  Nerves. — Have  patient  to  swallow  liquid  and  note 
any  regurgitation  through  the  nose.  Ask  the  patient  to  say 
"ah,"  and  note  if  both  the  sides  of  the  palate  are  raised 
equally. 

Spinal  Accessory  Nerves. — Have  the  patient  to  shrug 
the  shoulders,  also  to  rotate  the  chin  from  side  to  side,  noting 
any  difference  in  the  movements. 

Hypoglossal  Nerves. — Protrude  the  tongue,  and  note  the 
presence  of  any  deviation,  or  any  atrophy. 

Motor  Functions. — 

Compare  strength  of  corresponding  groups  of  muscles  in 
the  upper  and  the  lower  extremities.  Examine  for  muscular 
incordination  in  the  upper  and  lower  extremities.  Note  state 
of  nutrition  of  the  muscles,  and  presence  of  any  atrophy. 
Examine  for  abnormal  muscular  movements  such  as  tonic 
spasms,  clonic  spasms,  contractures,  tetany,  convulsions,  in- 
tention tremor,  fibrillary  twitchings,  choreic  movements, 
athetosis.  Examine  for  any  muscular  rigidity  or  flaccidity. 
Test  for  the  presence  of  Kernig's  sign. 

Sensory  Functions. — 

Test  for  common  sensibility  with  feather  or  cotton.  Note 
the  presence  of  areas  of  anesthesia  or  hyperesthesia.  Test 
for  sense  of  pain.  Use  pin  point  and  note  the  presence  of 
areas  of  analgesia,  hyperalgesia,  or  delayed  conduction.  Test 
for  temperature  sense,  using  test  tubes  with  warm  and  cool 
water.     Test  for  muscular  sense,  both  as  to  sense  of  weight 


Physical  Examination  of  the  Patient.  17 

and  position.  Inquire  as  to  any  abnormal  sensations,  such  as 
girdle  pain,  formications,  pins  and  needles  sensations,  or 
numbness. 

Reflexes. — 

Superficial  Reflexes. — Test  for:  (a)  Plantar  reflex, 
(Babinski's  sign  is  an  extensor  plantar  reflex  occurring 
chiefly  in  pyramidal  tract  lesions),  (b)  Conjunctival  reflex; 
(c)  Pupil  reflex;  (d)  Palate  reflex;  (e)  Cremasteric  reflex; 
(f)  Abdominal  reflex;  (g)  Epigastric  reflex. 

Deep  Reflexes. — Test  for:  (a)  Knee  jerk;  (b)  Ankle 
jerk;  (c)  Elbow  jerk;  (d)  Jaw  jerk;  (e)  Ankle  clonus;  (f) 
Patella  clonus. 

Organic  Reflexes. — Inquire  as  to:  (a)  Deglutition;  (b) 
DefiPcation;  (c)  Micturition;  (d)  Incontinence,  hesitancy  or 
retention  of  urine. 

Examination  of  the  Locomotor  System. 

Examine  shafts  of  bones  for  signs  of  former  fractures, 
thickening  of  periosteum,  or  the  presence  of  tenderness.  Ex- 
amine the  ends  of  the  bones  for  enlargement  as  in  rickets  or 
nodules  as  in  rheumatoid  arthritis.  Examine  joints  for  the 
presence  of  swelling,  tenderness,  fluctuation,  or  redness.  Ob- 
serve the  degree  of  motility  in  every  direction.  Examine  the 
vertebral  column  for  the  presence  of  tenderness,  local  projec- 
tions, lordosis,  kyphosis,  scoliosis,  and  mobility  of  the  vertebra. 

EX.VMINATION  OF  THE  Gait. —  (a)  Spastic  gait,  as  occurs  in 
hemiplegia;  (b)  Ataxia  gait,  as  occurs  in  tabes;  (c)  Reeling 
gait,  as  in  a  drunkard;  (d)  Festinant  gait,  as  in  paralysis 
agitans;  (e)  Waddling  gait,  as  in  pseudohypertrophic  mus- 
cular paralysis;  (f)  High  stepping  gait,  as  in  multiple  per- 
ipheral neuritis. 

Romberg's  Sign. — Test  for  its  presence. 

Examination  of  Eyes,  Ears,  Nose,  and  Larynx. 
Eyes. — 

(a)  Pupils  (size,  equality,  shape,  reflexes,  Argyll  Robert- 
son) ;    (b)   Strabismus;    (c)   Ptosis;    (d)   Nystagmus    (lateral 


18  .Diagnostic  Methods. 

or  vertical);  (e)  Conjunctivitis;  (f)  Exophthalmos;  (g) 
Vision  (hemianopsia,  condition  of  retina)  ;  (h)  Oedema  of 
lids. 

Ears. — 

(a)  Hearing;  (b)  Discharge;  (c)  Examination  of  canal 
for  foreign  bodies,  or  wax;  (d)  Examine  tympanum;  (e) 
Note  any  tenderness  over  mastoid. 

Nose. — 

(a)  Discharges;  (b)  Deformities;  (c)  Tumors;  (d)  Epis- 
taxis;  (e)  Deviations  of  septum;  (f)  Presence  of  spurs;  (g) 
Enlarged  turbinates. 

Larynx. — 

If  there  are  any  voice  changes,  a  laryngoscopic  examina- 
tion is  indicated. 


CHAPTER    III. 
SPUTUM. 

Origin. — May  be  from  mouth,  nose,  pharynx,  larynx, 
bronchi  or  lungs.  One  or  more  or  all.  Note  whether  hawked 
up  or  coughed  up. 

Quantity. — The  quantity  varies  within  wide  limits;  as  in 
early  tuberculosis  it  is  small,  but  in  chronic  bronchitis  or 
bronchiectasis  it  is  large. 

Odor.— Ordinarily  there  is  no  odor  to  sputum.  In  case  of 
abscess  or  gangrene  of  the  lung  it  may  be  very  disagreeable. 

Sputum  for  ExamiNx\tion  should  be  coughed  up  and  not 
hawked.  In  case  of  children  it  may  be  necessary  to  insert  a 
swab  in  the  pharjaix,  and  as  a  result  of  this  irritation  the 
sputum  will  be  coughed  up  and  can  be  removed  before  it  is 
swallowed. 

When  a  Specimen  op  Sputum  Is  Received,  pour  the 
sputum  in  a  petri  dish  and  place  on  cover.  Place  the  sputum 
container  in  water  and  boil.  Treat  also  in  this  manner  the 
petri  dish  and  sputum  after  examination. 

Macroscopic  Examination  of  the  Sputum. — 

This  shows  the  following : 

1.  Mucous  or  Viscid  Sputum. — Seen  in  early  stages  of 
bronchitis  and  pneumonia. 

2.  Mucopurulent  Sputum. — This  is  the  most  common 
form  and  is  not  characteristic  of  any  particular  condition. 

3.  Purulent  Sputum. — This  is  seen  in  pure  form  only  in 
perforation  into  the  lungs  or  bronchi  of  foci  of  pus,  as  in 
abscess  of  lung  or  empyema. 

4.  Serous  Sputum. — This  is  often  slightly  red  in  color 
and  frothy.  The  red  color  is  due  to  blood.  This  sputum  is 
characteristic  of  pulmonary  oedema. 

(19) 


20  Diagnostic  Methods. 

5.  Nummular  Sputum. — Each  part  expectorated  tends  to 
collect  to  itself.    This  is  common  in  tuberculosis  of  the  lungs. 

6.  Hemorrhagic  Sputum.~T\ih  is  seen  in  phthisis,  pneu- 
monia, epistaxis,  abscess  of  lung,  hemorrhagic  infarction, 
new  growths  and  passive  congestion. 

7.  Tenacious  Sputum. — Adheres  to  an  inverted  cup.  This 
is  seen  in  pneumonia. 

Note  the  Color  of  Sputum  as  follows : 

1.  Rusty  or  Orange  Juice  in  color.  This  is  common  in 
pneumonia. 

2.  Prune  Juice  in  Appearance.  Sometimes  seen  in  pneu- 
monia and  often  in  cancer  and  gangrene  of  lungs. 

3.  Grass-Green.  This  is  seen  in  pneumonia  in  combina- 
tion with  jaundice. 

4.  Black  or  Gray.  This  is  due  to  substances  inhaled,  as 
coal  dust.  The  sputum  may  be  gray  or  black  from  food,  as 
chocolate ;  and  also  tobacco. 

5.  Reddish-Yellow.  Seen  when  abscess  of  liver  ruptures 
into  lung. 

6.  Hemorrhagic  Sputum.  Seen  in  pulmonary  tuberculo- 
sis, pulmonary  infarcts,  passive  congestion  of  lungs,  lobar 
pneumonia,  leaking  aneurysm,  and  tuberculosis  of  lungs,  etc. 

Microscopic  Examination  Should  be  Made  for  the  following : 

1.  Unimportant  Constituents  Often  Seen. —  (a)  leuco- 
cytes; (b)  a  few  red  blood  cells;  (c)  epithelial  cells,  both 
squamous  and  columnar  in  type;  (d)  "heart  failure"  cells, 
pigmented  epithelial  cells  from  lining  of  the  alveoli :  results 
from  passive  congestion  of  lungs;  (e)  various  bacteria;  (f) 
particles  of  food. 

2.  Important  Constituents  to  he  Examined  for: 

(a)  Bacteria:  this  includes,  the  tubercle  bacillus,  influ- 
enza bacillus,  pneumococcus,  streptococcus,  staphylococcus 
and  Friedlander's  bacillus. 

(b)  Elastic  Fibers;  this  is  seen  in  all  destructive  proc- 
esses of  the  lungs,  as  phthisis,  gangrene  and  abscess. 


Sputum.  21 

(c)     Curschmann's  Spirals  and  Charcot-Leyden  Crystals. 

For  an  examination,  microscopically,  of  the  sputum  for 
leucocytes,  epithelial  cells,  influenza  bacillus,  Friedlander's 
bacillus,  streptococcus  and  staphylococcus  the  Loffler's  methy- 
lene-blue  stain  is  sutflcient. 

This  is  as  follows: 

1.  Make  cover  glass  preparation  from  a  purulent  particle 
of  the  sputum  and  spread  it  thinly.     Dry  in  air. 

2.  Fix  by  passing  through  flame  three  times. 

3.  Stain  in  Loffler's  methylene-blue  for  30  seconds,  heat- 
ing to  the  steaming  point,  or  1  to  2  minutes  without  heating. 

4.  Wash  in  water,  dry,  and  mount  in  balsam. 

Method  of  Staining  Bacillus  Tuberculosis  in  Sputum. — 

1.  Select  a  purulent  or  cheesy  particle  from  the  sputum 
and  smear  it  thinly  on  a  slide  and  let  it  dry  in  the  air. 

2.  Fix  the  specimen  by  passing  through  flame  four  or 
five  times. 

3.  Cover  with  carbol-fuchsin  solution  and  steam  from 
two  to  three  minutes  over  Bunsen  burner  or  alcohol  lamp. 
Do  not  let  the  stain  dry,  but  add  more  of  the  stain  if  neces- 
sary. 

4.  Wash  in  water. 

5.  Decolorize  in  acid  alcohol  until  a  pinkish  tinge  remains. 

6.  Wash  in  water. 

7.  Cover  the  specimen  with  Loffler's  methylene-blue  solu- 
tion for  30  seconds. 

8.  Wash  in  water,  dry,  mount  in  balsam  and  examine 
with  oil  immersion  lens.  The  tubercle  bacilli  are  stained 
bright  red,  nuclei  and  other  bacteria  are  blue. 

Method  of  Staining  the  Pneumococcus. — 

The  pneumococcus  may  be  stained  by  the  Loffler's  methy- 
lene-blue solution,  but  probably  the  most  satisfactory  method 
is  Gram's  stain. 


22  Diagnostic  Methods. 

Reagents  required  for  Gram's  stain: 

1.  Anilene  water,  made  by  placing  3  to  5  c.c.  of  anilene 
oil  in  test  tube,  and  four  times  this  quantity  of  tap  water. 
Shake  wel],  and  filter  through  two  sheets  of  filter  paper. 

2.  Anilene  water  gentian  violet,  made  by  adding  two  or 
three  drops  of  saturated  alcoholic  solution  of  gentian  violet 
to  the  anilene  water,  and  filter. 

3.  Gram's  iodine  solution.  (See  composition  of  reagents.) 

4.  Diluted  carbol-fuchsin :  Made  by  adding  two  (2)  parts 
of  water  to  one  part  of  carbol-fuchsin,  then  filter. 

Following  is  the  Method  of  Gram's  Stain: 

1.  Cover  the  cover  glass  containing  the  smear  with  ani- 
lene water  gentian  violet  for  2  to  3  minutes;  blot  dry. 

2.  Gram's  iodine  for  1"^/^  minutes;  blot  dry. 

3.  95  per  cent  alcohol ;  pour  on  and  off  until  all  the  blue 
color  comes  away. 

4.  Wash  in  water. 

5.  Diluted  carbol-fuchsin  (1  to  2  with  water)  for  one- 
half  to  one  minute. 

Wash  in  water,  mount  and  examine.  The  pneumococcus 
and  all  Gram  positive  organisms  are  colored  blue.  All  Gram 
negative  organisms  are  colored  red. 

Examination  for  Elastic  Fibers. — 

Take  8  c.c.  of  sputum  and  equal  amount  of  10  per  cent 
sodium  hydrate,  shake  well  and  heat  the  mixture  (but  keep 
below  the  boiling  point)  until  whole  mass  is  liquified.  Dilute 
with  water,  centrifugalize.  Pour  off  supernatant  fluid.  Make 
a  thick  smear  on  slide  from  the  sediment  and  let  it  dry  in  the 
air.  Cover  smear  with  Weigert  elastic  tissue  stain  and 
steam  for  4  minutes,  but  be  careful  to  prevent  alcohol  from 
catching  fire.  Wash  gently  in  water.  Decolorize  for  one 
minute  with  95  per  cent  alcohol.  Wash  in  water.  Dry  and 
mount  and  examine  under  dry  lense  for  elastic  fibers,  which 
appear  blue  and  wavy. 

An  examination  should  be  made  for  Curschmann's  Spirals 
and  Charcot-Leyden  Crystals  in  the  sputum  of  every  case  of 


Sputum.  23 

bronchial  asthma.  Use  a  two-thirds  objective.  The  Cursch- 
mann  Spirals  appear  as  twisted  spirals  of  glossy  transpar- 
ency. Macroscopically  they  appear  as  twisted  shreds  about 
1  m.m.  thick  and  1  to  2  centimeters  long,  and  are  composed 
of  mucous  threads.  The  Charcot-Leyden  crystals  are  not  so 
frequently  present.  They  are  transparent  and  octahedral 
crystal. 

Sputum  in  Disease. 
Tuberculosis. — 

In  the  early  sfnyes,  none  at  all  or  small  in  amount;  occurs 
most  often  early  in  the  morning,  and  has  a  mucoiLS  or  slight 
mucopurulent  appearance.  This  may  contain  tubercle  ba- 
cilli. As  the  disease  progresses  it  becomes  more  and  more 
mucopurulent,  and  finally  purulent  with  cheesy-looking  par- 
ticles. It  is  then  nummular  in  character.  Amount  of  spu- 
tum gradually  increases  from  almost  none  in  the  early  stages 
to  large  quantities  in  the  advanced  stages. 

Blood  is  present  in  almost  all  cases  at  some  stages  of  the 
disease.  In  early  cases  the  sputum  is  only  streaked  with 
blood,  while  larger  hemorrhages  are  more  apt  to  be  seen 
later.  Cheesy  particles  are  observed  in  the  moderately  ad- 
vanced and  advanced  cases.  They  usually  contain  tubercle 
bacilli  in  large  numbers. 

Sputum  in  Pneumonia. — 

In  young  children  and  the  very  old  often  there  is  no  ex- 
pectoration. The  sputum  is  at  first  mucoid,  but  sooner  or 
later  becomes  bloody  to  a  greater  or  less  degree,  and  in  fully 
one-third  of  the  cases  it  is  rusty  in  appearance.  It  is  very 
tenacious,  and  adheres  to  the  cup  when  inverted.  Prune 
juice  sputum  is  often,  but  not  always  an  evil  omen,  as  it  in- 
dicates a  serious  condition. 
t 

In  cases  of  abscess  or  gangrene  complicating  the  pneu- 
monia, the  sputum  is  more  fluid;  disagreeable  odor  especially 
in  gangrene,  and  the  color  is  coffee-like  or  chocolate  brown. 
Microscopically  one  finds  pus  cells,  epithelial  cells,  red  blood 
cells  and  pneumococcus. 


24  Diagnostic  Methods. 

Sputum  in  Bronchiectasis. — 

Usually  very  abundant,  and  often  mouthful  at  a  time; 
color  is  grayish-yellow,  which  may  show  red  or  brown  pig- 
ment; odor  usually  disagreeable,  especially  if  putrefactive 
changes  have  taken  place  in  the  bronchitic  cavities. 

Microscopically  one  finds  pus  cells,  alveolar  epithelial  cells, 
few  red  blood  cells,  and  an  immense  number  of  bacteria. 

Sputum  in  Bronchitis. — 

Early  in  the  attack  the  sputum  is  scanty,  mucoid,  and 
highly  tenacious,  occasionally  streaked  with  blood.  As  the 
bronchitis  continues  the  sputum  becomes  progressively  more 
purulent,  which  gives  it  a  yellow  color. 

Microscopically  one  finds  leucocytes,  ciliated  epithelial 
cells,  a  few  blood  cells,  and  bacteria. 

Sputum  of  Bronchial  Asthma. — 

During  the  paroxysm  there  is  often  no  sputum.  If  pres- 
ent it  is  scanty  in  amount,  and  occurs  as  grayish  mucoid 
masses.  As  the  attack  passes  off  sputum  appears.  It  is  then 
fairly  abundant,  thin  and  frothy  and  contains  mucopurulent 
masses.  The  sputum  contains  Curschmann's  Spirals,  mucous 
moulds  of  the  smaller  bronchi,  and  sometimes  fibrinous  casts. 

Microscopically  one  finds  many  eosinophilic  leucocytes, 
which  is  of  some  diagnostic  importance.  Charcot-Leyden 
crystals  are  often  found. 


CHAPTER   IV. 

URINE. 

Get  (juaiitity  in  24  hours.  In  suspected  nephritis  separate 
day  and  night  portions.  Note  color,  odor,  reaction,  and  spec- 
ific gravity. 

Preservation  of  Urine. 

Specimens  may  be  preserved  by: 

1.  The  addition  of  40  per  cent  formalin  in  the  propor- 
tion of  30  drops  to  a  liter  of  urine. 

2.  Cold  storage. 

3.  Chloroform  in  the  jDroportion  of  20  drops  to  4  ounces. 
Use  tightly  corked  bottle. 

4.  Thymol,  2  or  3  crystals  to  4  ounces. 

Turbidity. 

Cloudiness  of  urine  may  be  due  to  precipitation  of  phos- 
phates, or  urates,  or  may  be  due  to  pus,  bacteria  or  fat.  If 
cloudiness  is  due  to  urates  it  will  clear  up  on  heating;  if  due 
to  phosphates,  with  a  few  drops  of  acetic  acid;  if  due  to  fats 
it  will  clear  up  by  shaking  with  equal  quantity  of  ether.  If 
due  to  bacteria,  clear  up  by  the  addition  of  aqueous  solution 
of  ferric  chloride  and  then  ammonium  hydrate,  and  then 
filter.  Cloudiness  from  red  blood  cells,  pus,  bacteria  and 
cellular  elements  may  be  determined  by  microscopical  exam- 
ination. 

Chemical  Examination  of  the  Urine. 

A  quantitative  examination  should  be  made  for  the  fol- 
lowing abnormal  constituents  of  the  urine:  (a)  any  albumen, 
(b)  serum-albumen,  (c)  albumose,  (d)  nucleo-albumen,  (e) 
serum-globulin,    (f)   hsemoglobin,    (g)    bile,    (h)    indican,    (i) 

(25) 


26  Diagnostic  Methods. 

sugar,    (j)    acetone,    (k)    diacetic   acid,    (1)    Beta-oxybutyric 
acid,  (m)  Diazo  su)3stances. 

Chemical  Test  for  Albumen. — 

1.  Nitric  Acid  or  Heller's  Test.  —  This  reacts  to  all 
urinary  proteids  except  peptone.  Place  5  c.c.  or  thereabouts 
of  colorless  nitric  acid  in  the  bottom  of  a  test  tube.  Incline 
the  test  tube,  and  place  in  equal  amount  of  clear  filtered 
urine  with  a  pipette.  A  white  precipitate  of  albumen  forms 
at  the  junction  of  the  two  fluids,  if  albumen  is  present  in  the 
urine.  A  cloudy  precipitate  higher  in  the  urine  may  be  due 
to  urates.  Bile  and  an  excess  of  urinary  coloring  matter  may 
give  a  colored  precipitate  at  the  junction  of  the  two  fluids. 
This  is  a  very  accurate  test,  as  it  shows  fairly  definitely  even 
to  as  small  amount  as  1/1000  of  1  per  cent  of  albumen  in  the 
urine. 

2.  Heat  Test.' — Pour  10  c.c.  of  clear  filtered  urine  into  a 
test  tube  and  1/10  of  its  volume  of  saturated  sodium  chlo- 
ride solution  may  or  may  not  be  added,  and  then  boil  the 
upper  half  of  the  fluid.  Add  3  to  4  drops  of  25  per  cent 
acetic  acid  and  boil  again.  .  A  precipitate  appearing  on  boil- 
ing, which  persists  after  the  addition  of  the  acid,  or  appear- 
ing on  the  second  boiling,  is  albumen.  One  disappearing  with 
the  addition  of  the  acid  is  phosphates.  The  test  may  fail  if 
too  much  acetic  acid  is  added.  This  is  one  of  the  most  deli- 
cate tests  for  albumen. 

Acetic  Acid  and  Potassium  Ferrocyanide  Test. — 

Make  8  or  10  c.c.  of  clear  filtered  urine  strongly  acid  with 
25  per  cent  acetic  acid — 12  to  15  drops.  Then  add  drop  by 
drop  a  5  per  cent  solution  of  potassium  ferrocyanide.  A 
white  flocculent  precipitate  is  formed  if  albumen  is  present. 

Picric  Acid  Test. — 

To  8  or  10  c.c.  of  clear  filtered  urine  add  a  few  drops  of 
Esbach's  reagent.  The  appearance  of  a  precipitate  indi- 
cates presence  of  albumen. 

Chemical  Tests  for  Serum-albumen. — 

Add  to  a  test  tube  half  filled  with  filtered  urine  one-fifth 
of  its  volume  of  a  saturated  aqueous  solution  of  sodium  chlo- 


Urine.  27 

ride,  heat  to  a  boiling  point ;  add  2  to  5  drops  of  50  per  cent 
acetic  acid  and  heat  again.  The  persistence  of  a  precipitate 
indicates  serum-albnmen. 

Chemical  Test  for  Nucleo-albumen. — 

Place  in  a  test  tube  5  c.c.  of  urine,  and  nearly  fill  test  tube 
with  water.  Divide  this  into  equal  parts.  Use  one  as  a  con- 
trol, and  to  the  other  add  4  drops  of  50  per  cent  acetic  acid 
without  heating.  A  cloudiness  indicates  the  presence  of  nu- 
cleo-albumen. 

Chemical  Test  for  Serum-globulin. — 

Fill  two  test  tubes  about  two-thirds  with  distilled  water. 
Use  one  as  a  control,  and  to  the  other  add  10  drops  of  urine 
drop  by  drop.  A  cloudiness  indicates  the  presence  of  serum- 
globulin. 

Chemical  Test  for  Albumose. — 

Take  8  c.c.  of  urine  and  add  nitric  acid,  drop  by  drop,  till 
you  get  a  permanent  precipitate.  Heat  to  the  boiling  point 
and  the  precipitate  will  partially  disappear.  Cool  upper 
part  with  water  and  it  will  reappear.  Repeat  this  again  till 
you  are  sure  it  is  albumose.  The  nitric  acid  converts  the  al- 
bumen into  an  acid  albuminate  which  is  soluble,  but  the  al- 
bumose is  not  affected. 

Chemical  Examination  for  Hsemogiobin. — 

To  about  10  c.c.  of  urine  in  a  test  tube  add  2  c.c.  of  glacial 
acetic  acid  and  15  c.c.  of  ether.  Shake  gently  for  1  or  2  min- 
utes. After  the  ether  has  separated,  decant.  Add  to  the  ethe- 
rial  solution  10  drops  of  a  freshly  prepared  tincture  of  guaiac 
and  30  drops  of  hydrogen  peroxide.  A  blue  color  indicates 
the  presence  of  blood  or  blood  coloring  matter  (hasmoglobin). 

Chemical  Examination  for  Bile. — 

Iodine  Test.  (Tine,  iodine  1  part,  alcohol  15  parts.)  Pour 
2  c.c.  of  the  iodine  solution  on  the  top  of  the  urine  in  a  test 
tube.  A  green  ring  at  the  junction  of  the  two  fluids  shows 
bile. 


28  Diagnostic  Methods. 

Chemical  Examination  for  Indican. —  . 

(1)  To  8  or  10  c.c.  of  clear  filtered  urine  add  about  2  c.e.  of 
5  per  cent  copper  sulphate  solution,  and  3  c.c.  of  chloroform, 
and  a  quantity  of  concentrated  hydrochloric  acid  equal  to 
number  of  c.c.  already  present.  Invert  test  tube  a  few  times 
gently.  The  amount  of  indican  present  is  proportional  to 
the  depth  of  color  of  the  chloroform  extract.  (2)  To  about 
10  c.c.  of  clear  filtered  urine  add  equal  quantity  of  concen- 
trated hydrochloric  acid  which  contains  in  100  c.c.  .4  gram 
of  ferric  chloride.  Shake  well,  then  add  3  to  4  c.c.  of  chloro- 
form and  shake  again.  The  chloroform  will  become  blue  if 
indican  is  present. 

Sugar. — 

If  albumen  is  present  in  more  than  a  trace,  the  urine  should 
be  acidified  with  several  drops  of  25  per  cent  acetic  acid, 
heated  to  precipitate  the  albumen  and  then  filtered. 

1.  F Billing 's  Test, — Add  equal  quantities  of  the  copper 
solution  and  alkaline  solution.  Dilute  3  to  4  times  with  wa- 
ter. Boil  the  upper  fourth  of  the  Fehling's  solution  and 
then  add,  at  once,  1  or  2  drops  of  the  urine.  If  sugar  is 
present  you  will  get  a  reddish  precipitate.  Do  not  boil  a  sec- 
ond time  if  there  is  no  precipitate,  but  set  aside  for  a  few 
hours  and  then  examine  for  precipitate.  If  you  should  boil 
a  second  time  and  then  no  reddish  precipitate  appears  there 
is  no  sugar  present,  but  a  reddish  precipitate  might  then  be 
due  to  other  things  in  the  urine  than  sugar. 

2.  Phenyl-hydrazine  Test. — To  5  c.c.  of  the  clear  filtered 
urine  add  5  c.c.  of  the  phenyl-hydrazine  acetate  solution. 
Heat  to  the  boiling  point  in  the  water  bath  for  30  to  45  min- 
utes, then  allow  it  to  cool  gradually.  Place  some  of  the  yel- 
low precipitate  on  a  slide  and  then  examine  microscopically 
for  the  needle-like  crystals  of  phenyl-glucosazone.  Both  glu- 
cose and  levulose  give  identical  crystals. 

3.  Nylander's  Test. — Add  1  c.c.  of  Nylander's  reagent  to 
10  c.c.  of  clear  filtered  urine  in  a  test  tube.  Boil  upper  part 
2  or  3  minutes.  If  sugar  is  present  the  fluid  assumes  first  a 
yellow  then  yellowish-brown  and  finally  an  almost  black 
color,  and  after  some  time  a  black  sediment  forms. 


Urine.  29 

4.  Fermentation  Test. — To  some  of  the  urine  add  a  little 
fresh  yeast.  Fill  the  tube  provided  for  the  purpose  with  the 
mixture.  In  a  second  tube  place  water  containing  a  little 
yeast.  In  a  third  tube  place  some  of  the  urine  without  yeast. 
Place  in  a  warm  room,  or  in  an  incubator  until  the  next  day, 
and  note  the  presence  of  the  CO2  gas. 

5.  Trommer's  Test. — Add  to  5  c.c.  of  the  clear  filtered 
urine  an  equal  volume  of  strong  sodium  hydrate  solution, 
then  drop  by  drop  a  1  per  cent  solution  of  copper  sulphate 
as  long  as  the  precipitate  formed  continues  to  dissolve  read- 
ily. Heat  upper  part,  and  a  reddish-yellow  precipitate 
means  the  presence  of  glucose. 

Acetone. — 

To  one-sixth  of  a  test  tube  of  urine  add  a  crystal  of  sodium 
nitro  prusside.  Make  strongly  alkaline  with  10  per  cent  so- 
dium hydroxide  solution.  Shake.  The  addition  of  a  few 
drops  of  glacial  acetic  acid  gives  a  purple  color  to  the  foam 
if  acetone  is  present. 

Diacetic  Acid. — 

Add  a  strong  aqueous  solution  of  ferric  chloride  to  one- 
third  of  a  test  tube  of  urine.  A  burgundy  red  color  shows 
the  presence  of  diacetic  acid.  If  this  reaction  takes  place 
after  the  urine  has  been  previously  boiled,  it  is  not  due  to 
diacetic  acid. 

Beta-oxybutyric  Acid. — 

In  testing  for  diacetic  acid,  if  the  ferric  chloride  reaction 
is  strongly  positive  Beta-oxybutyric  acid  is  probably  pres- 
ent. 

Diazo  Substances. — 

To  5  c.c.  of  sulphanilic  acid  solution  add  2  drops  of  a  .5 
per  cent  fresh  solution  of  sodium  nitrite.  Add  an  equal 
quantity  of  urine.  Shake  and  add  quickly  2  or  3  c.c.  of  10 
per  cent  ammonium  hydrate  solution.  A  carmine  color,  espe- 
cially in  the  foam,  shows  a  positive  diazo  reaction.  If  the 
reaction  is  positive  and  the  mixture  is  allowed  to  stand  for 


30  Diagnostic  Methods. 

24  hours  a  precipitate  forms,  the  upper  margin  of  which  ex- 
hibits a  green,  greenish-black  or  violet  zone. 

Quantitative  Examination  of  the  Following  Normal 
Constituents  of  the  Urine. 

(a)  Chlorides;  (b)  Urea;  (c)  Total  acidity;  (e)  Total 
solids. 

Chlorides. — 

Take  10  c.c.  of  clear,  filtered  urine;  add  to  this  50  c.c.  of 
distilled  water,  5  c.c.  of  5  per  cent  ammonium  iron  alum  solu- 
tion, 10  c.c.  of  concentrated  nitric  acid,  and  20  c.c.  of  stand- 
ard silver  nitrate  solution.  Increase  the  quantity  to  exactly 
100  c.c.  with  distilled  water,  shake  and  filter ;  measure  out  50 
c.c.  of  the  filtrate  in  a  beaker,  and  titrate  with  standard  am- 
monium sulphocyanate  solution  until  a  reddish-brown  tint 
first  extends  throughout  the  whole  liquid. 

The  amount  of  sulphocyanate  used  multiplied  by  two  gives 
at  once  the  excess  of  silver  nitrate  used  beyond  the  quantity 
required  to  precipitate  all  the  chlorides  in  the  10  c.c.  of 
urine.  Knowing  the  original  number  of  c.c.  of  silver  nitrate 
taken,  and  the  excess,  the  difference  will  give  the  number 
used  up,  and  each  c.c.  of  this  equals  10  mgms.  of  sodium 
chloride.  This  is  multiplied  by  (1/10)  one-tenth  of  the 
24-hour  quantity  of  urine  to  get  amount  of  sodium  chloride 
excreted  in  24  hours. 

Urea. — 

Use  Doremus-Hinds  ureameter.  Fill  the  large  tube  with  a 
mixture  of  sodium  hydrate  solution  and  bromine  solution  in 
the  proportion  of  15  c.c.  of  the  former  to  1  c.c.  of  the  latter. 
Fill  the  smaller  tube  to  the  zero  point  with  urine.  Now  very 
gradually  allow  1  c.c.  of  the  urine  to  pass  into  the  mixture 
in  the  large  tube.  Urea  is  decomposed  and  nitrogen  gas  is 
liberated  and  collects  at  the  top.  If  the  level  of  the  fiuid 
stands  at  .015,  then  1  c.c.  of  the  urine  contained  .015  grams 
of  urea.  This  must  be  multiplied  by  number  of  c.c.  in  24- 
hour  quantity  to  get  total  quantity  of  urea  passed  in  that 
length  of  time. 


Urine.  31 

The  Doremus  ureameter  differs  from  the  Doremus-Hinds 
in  that  a  1  e.c.  graduated  pipette  is  non-attached  and  is 
therefore  less  convenient.  One  c.c.  of  the  urine  is  added  to 
the  solution  and  after  the  bubbles  of  gas  have  ceased  to  rise, 
make  the  reading  and  estimation  in  the  same  manner  as  the 
above. 

Total  Acidity. — 

Take  25  c.c.  of  urine,  add  to  this  2  c.c.  of  saturated  potas- 
sium oxalate  solution:  then  two  or  three  drops  of  1  per  cent 
phenolphthalin  solution.  Titrate  this  with  decinormal  so- 
dium hydrate  solution  until  the  first  change  to  red  color  takes 
place.  This  represents  the  neutralization  of  all  the  acids  in 
25  c.c.  of  the  urine.  From  this  estimate  quantity  in  a  24- 
hour  specimen.  The  normal  is  about  400  expressed  in  terms 
of  decinormal  sodium  hydrate  solution. 

Total  Solids.— 

This  is  estimated  by  multiplying  the  last  two  figures  of 
the  specific  gravity  of  a  mixed  24-hour  urine  by  2.33.  Then 
multiply  the  product  by  the  number  of  cubic  centimeters 
voided  in  24  hours  and  divide  by  1,000.  This  will  give  ap- 
proximately the  total  solids  expressed  in  grams. 

Quantitative  Examination  of  the  Following  Abnormal 
Constituents  of  the  Urine; 

(a)   Albumen;    (b)   Sugar;    (c)   Indican. 

Albumen. — 

An  approximate  idea  of  the  quantity  of  albumen  can  be 
obtained  by  boiling  10  c.c.  of  urine  acidified  with  two  drops 
of  50  per  cent  acetic  acid  and  allowing  the  albuminous  pre- 
cipitate to  settle  for  24  hours.  If  the  albumen  amounts  to 
2  or  3  per  cent  the  fluid  will  be  converted  into  an  almost  com- 
pact coagulum.  One  per  cent  of  albumen  in  the  urine  the 
precipitate  wall  occupy  half  the  column  of  urine,  five-tenths 
per  cent  of  albumen  will  occupy  one-third,  one-tenth  per 
cent  will  occupy  one-tenth  the  volume,  five-hundredths  per 


32  Diagnostic  Methods. 

cent  will  cover  the  bottom  of  the  test  tube.  One-hundredth 
per  cent  or  less  causes  a  turbidity,  but  no  precipitate. 

Method  of  Eshach. — This  method,  while  not  accurate,  is 
convenient  and  applicable.  Fill  the  Eshach  albuminometer 
to  the  line,  marked  "U"  with  the  urine,  and  fill  to  the  line 
marked  "R"  with  Eshach 's  reagent.  Close  the  tube,  and  by 
repeated  inversions  thoroughly  mix  the  two  fluids.  Do  not 
shake.  Set  aside  in  natural  position  for  24  hours,  when  the 
precipitated  proteid  will  settle  to  the  bottom.  The  gradua- 
tions indicate  the  grams  of  proteids  in  a  liter  of  the  urine. 
If  amount  of  proteid  is  large,  it  will  be  necessary  to  dilute 
urine. 

Modification  of  Esdach. — This  method  differs  from  Es- 
hach's  simply  in  the  addition  of  10  drops  of  a  10  per  cent 
ferric  chloride  solution  to  the  measured  amount  of  urine 
after  it  is  put  in  the  tube,  and  before  Eshach 's  reagent  is 
added.  Mix  gently,  and  place  the  tube  in  a  water  bath  at  a 
temperature  of  72°  C.  Precipitation  begins  almost  immedi- 
ately and  is  complete  in  an  hour  or  so,  when  the  result  is 
read  in  the  usual  manner. 

Tsuchiya's  Modification  of  Eshach's  Method.  —  Acidify 
urine  with  a  few  drops  of  25  per  cent  acetic  acid.  Fill  Eshach 
tube  with  urine  to  mark  "U,"  and  then  Tsuchiya's  reagent  lo 
mark  * '  R. "  Cork  and  invert  12  times  to  mix  well.  Place  in 
vertical  position  at  room  temperature  for  24  hours,  and  then 
read  as  in  Eshach 's  method.  This  test  is  excellent  in  many 
respects. 

Indican. — 

To  10  c.c.  of  urine  add  1  c.c.  of  25  per  cent  lead  acetate  so- 
lution. Filter.  To  5  c.c.  of  the  filtrate  add  5  c.c.  of  Ober- 
mayer's  reagent  (concentrated  hydrochloric  acid,  500  c.c. 
ferric  chloride,  1  gm.).  Shake  gently.  Add  2  c.c.  of  chloro- 
form. Shake  and  let  stand  for  5  minutes.  A  blue  color  indi- 
cates the  presence  of  indican.  Now  drop  from  a  burette  a 
solution  of  potassium  chlorate  (34.64  gm.  to  a  liter  of  water) 
until  the  blue  color  disappears.  It  normally  requires  about 
3  drops.  If  indicanuria  is  present  it  may  require  10  to  15 
drops  or  more. 


Urine.  33 

Sugar:    Fehling's  Quantitative  Method. — 

Solution  A. — Copper  sulphate  solution.  Made  by  weigh- 
ing out  accurately  34.64  gnis.  of  purest  obtainable  copper 
sulphate,  and  dissolve  in  exactly  500  c.c.  of  distilled  water. 
10  c.c.  equals  .05  gm.  of  glucose. 

Solution  B. — Alkaline  tartrate  solution.  Dissolve  125  gms. 
of  sodium  hydroxide,  and  173  gms.  of  Rochelle  salts  in  500 
c.c.  of  distilled  water.  Place  5  c.c.  of  the  copper  sulphate  in 
a  moderately  large  flask,  and  add  an  equal  volume  of  the  al- 
kaline tartrate  solution.  Dilute  this  with  5  or  6  volumes  of 
water,  and  bring  to  a  boil.  Fill  a  burette  with  urine  to  be 
tested,  and  run  it  into  the  flask  until  the  color  of  the  solu- 
tion has  entirely  disappeared.  In  the  beginning  of  this  titra- 
tion .5  c.c.  of  urine  may  be  added  at  a  time  with  boiling  after 
each  addition.  Towards  the  end,  when  the  blue  color  has  al- 
most disappeared,  the  urine  should  be  added  more  cautiously, 
2  or  3  drops  at  a  time,  not  less  than  5  c.c.  of  the  urine  should 
be  used.  Urines  richer  in  sugar  should  be  diluted  accord- 
ingly. Three  determinations  should  be  made;  the  first  for 
an  approximate  estimate  and  to  see  the  extent  of  dilution  of 
the  urine ;  the  last  two  for  a  final  determination,  the  average 
being  taken. 

The  amount  of  copper  sulphate  solution  used  is  reduced 
by  .05  gm.  of  glucose.  This  amount  of  sugar,  then,  must 
therefore  be  in  the  volume  used  for  the  titration.  Calculate 
the  per  cent. 

Sugar:     (Quantitatively) — Modified  by  Rudische. — 

To  4  parts  by  volume  of  a  50  per  cent  solution  of  potas- 
sium sulphocyanate,  chemically  pure,  is  added  1  part  by  vol- 
ume of  a  mixture  of  equal  parts  of  Fehling's  copper  sulphate 
and  alkaline  solutions.  Place  25  c.c.  of  this  solution  in  a 
beaker,  and  the  urine  to  be  tested  added  drop  by  drop  from  a 
burette  until  the  blue  color  of  the  copper  entirely  disap- 
pears. Throughout  the  titration,  the  solution  should  be 
slowly  boiled  and  constantly  stirred  with  a  glass  rod.  The 
end  reaction  is  sharp,  the  fiuid  becoming  colorless  or  assum- 
ing a  faint  yellow  tinge.     Each  c.c.   of  the  reagent  is  re- 


34  Diagnostic  Methods. 

duced  by  1  M.  gm.  of  sugar :  therefore  it  takes  25  M.  gms.  of 
sugar  for  the  25  c.c.  of  the  reagent,  and  this  amount  of  sugar 
is  present  in  the  quantity  of  urine  used  in  the  titration. 

Examination  of  the  Urine  for  Bacillus  Tuberculosis. 

1.  Centrifugalize,  decant,  dilute  with  water  and  recentri- 
fugalize.  Make  a  cover  glass  preparation  from  the  sedi- 
ment. This  should  be  spread  thinly  and  dried  by  holding 
over  the  flame  of  a  Bunsen  burner.  Fix  by  passing  through 
the  flame  three  times. 

2.  Cover  the  preparation  with  carbol-fuchsin  and  steam 
over  a  flame  for  2  minutes.  Do  not  let  slide  become  dry,  but 
add  more  stain  if  necessary. 

3.  Wash  in  water. 

4.  Decolorize  in  acid  alcohol  until  the  red  color  is  re- 
moved and  faint  pink  is  seen. 

5.  Wash  in  water. 

6.  Cover  with  Loffler's  methylene-blue  for  30  seconds. 

7.  Wash  in  water  and  mount. 

The  tubercle  bacilli  are  bright  red;  nuclei  and  other  bac- 
teria are  blue.  The  alcohol  decolorizes  any  smegma  bacilli, 
but  absolute  differentiation  requires  inoculation  of  guinea- 
Pig- 

Microscopic  Examination  of  the  Urinary  Sediment. 

Centrifugalize  with  hand,  water  or  electric  centrifuge, 
and  examine  for  crystals,  fat  globules,  epithelial  cells,  red 
blood  cells,  pus  cells  and  casts.  Use  two-thirds  and  one-sixth 
lens. 

Epithelial  cells  are  recognized  by  the  presence  of  a  nu- 
cleus in  the  center  of  the  cell.  The  cells  may  be  of  various 
sizes  and  shape  depending  on  whether  they  originate  from 
urethra,  bladder,  ureter  or  kidney. 

Red  cells  are  recognized  by  their  spherical  shape,  and  ab- 
sence of  nucleus.  They  may  appear  only  as  circular  rings 
or  may  contain  some  haemoglobin. 


Urine.  35 

Piis  cells  (leucocytes)  appear  spherical  and  granular.  On 
addition  of  a  drop  of  dilute  acetic  acid  the  nucleus  will  be- 
come visible  and  its  shape  may  be  made  out. 

Casts  are  recognized  by  the  following  characteristics : 
Their  sides  are  parallel,  their  ends  are  square  or  somewhat 
irregular,  but  they  never  come  to  a  point.  They  are  divided 
into  the  following: 

1.  Hyaline  casts;  (a)  narrow,  (b)  broad. 

2.  Granular  casts;  (a)  finely  granular,  (b)  coarsely  gran- 
ular. 

3.  Waxy  casts. 

4.  Fatty  easts. 

5.  Casts  containing  organized  structures;  (a)  epithelial 
casts;   (b)  blood  easts;   (c)  pus  easts. 

Casts  must  be  distinguished  from  mucous  threads,  and 
eylindriods.  Mucous  threads  show  faint  longitudinal  stria- 
tions  and  taper  to  a  point  at  both  ends.  Cylindriods  are 
homogenous  like  hyaline  casts,  but  one  or  the  other  end 
tapers  to  a  point. 

Urine  in  Disease. 

Acute  Diffuse  Nephritis. — 

Quantity  of  urine  very  much  diminished,  depending  of 
course  on  its  severity. 

Specific  gravity  and  color  are  correspondingly  increased, 
the  color  is  often  smoky  from  the  presence  of  blood.  In 
other  cases  the  microscope  is  required  to  demonstrate  the 
blood.  Albumen  is  present  in  large  amounts,  1/8  to  1  per 
cent. 

Microscopical  examination  shows  the  presence  of  hyaline, 
granular  and  epithelial,  and  usually  also  blood  and  leuco- 
cytie  casts.  In  addition  there  are  renal  epithelial  cells  which 
sometimes  show  evidence  of  fatty  degeneration.  Leucocytes 
and  red  blood  cells  in  varying  numbers  are  seen. 

Chronic  Diffuse  Nephritis  (Large  White  Kidney). — 

Urine  diminished  in  quantity.  Specific  gravity  and  color 
correspondingly  increased.     Albumen  is  always  present  and 


36  Diagnostic  Methods. 

usually  in  a  greater  amount  than  in  the  acute   cases,   the 
amount  varies  from  I/4  to  1  per  cent. 

Microscopically  one  finds  hyaline,  granular,  fatty,  waxy 
and  epithelial  casts,  renal  epithelial  cells  undergoing  ex- 
tensive fatty  degeneration,  free  fat  globules,  leucocytes  and 
a  few  red  blood  cells.  If  an  acute  exacerbation  of  chronic 
diffuse  nephritis  occurs,  then  there  is  in  addition  to  the 
above,  more  blood  cells  and  blood  casts  in  the  urine,  the 
quantity  is  more  diminished  and  the  oedema  is  much  more 
extensive. 

Chronic  Interstitial  Nephritis  (Granular  Contracted 
Kidney). — 

The  urine  is  increased  in  quantity,  especially  at  night.  It 
is  pale  in  color.  Specific  gravity  is  diminished,  usually  be- 
tween 1,010  and  1,004. 

Albumen  is  present  in  traces,  but  at  times  may  not  be 
found. 

The  morning  urine  may  be  free  from  albumen  but  the 
evening  urine  may  contain  it.  It  is  necessary  to  centrifugal- 
ize  the  urine  to  obtain  sediment,  and  even  then  it  is  small  in 
amount. 

Microscopical  examination  shows  a  small  number  of  hya- 
line and  finely  granular  casts,  an  occasional  epithelial  cell 
and  a  few  leucocytes. 

Renal  Tuberculosis. — 

Early  in  the  case  polyuria  is  of  frequent  occurrence.  Often 
the  passage  of  blood  is  the  first  thing  to  attract  the  attention 
of  the  patient. 

The  blood  may  be  microscopic  only,  or  macroscopic.  It  is 
usually  intermittent,  the  average  length  of  the  bleeding  is 
three  days.  The  blood  and  the  urine  are  intimately  mixed. 
Pus  is  frequent  in  all  cases  in  which  the  pelvis  of  the  kidney 
is  involved.  Amount  is  very,  variable,  from  a  few  leuco- 
cytes to  14  the  volume  of  the  urine.  As  a  rule  this  pyuria 
is  constant. 

Albumen  is  of  course  always  demonstrable  whenever  blood 
or  pus  is  present — the  latter  by  itself  is  only  responsible  for 


Urine.  37 

a  trace;  casts  may  be  present,  but  they  are  not  a  constant 
factor  in  the  urinary  picture,  while  the  association  of  hema- 
turia and  pyuria  with  an  acid  urine  should  always  excite 
suspicion. 

The  diagnosis  of  renal  tuberculosis  demands  the  demon- 
stration of  the  tubercle  bacillus  as  well. 

Arteriosclerotic  Kidney. — 

Urinary  findings  the  same  as  in    chronic    interstitial    ne- 
phritis. 


CHAPTER  V. 
GASTRIC   CONTENTS. 

In  an  examination  of  stomach  contents  the  material  from 
a  fasting  stomach  and  also  the  contents  following  a  test  meal 
should  both  be  examined. 

It  is  best  to  obtain  the  contents  of  a  fasting  stomach  early 
in  me  morning,  as  in  normal  stomachs  no  food  should  be 
present;  if  it  is  present  it  is  a  sign  of  stasis.  If  as  much  as 
50  c.c.  of  fluid  is  obtained  it  indicates  hypersecretion  or 
stasis.  After  removing  the  fasting  contents  the  test  meal 
should  be  given. 

Test  Meal. 

This  consists  of  one  large  slice  of  bread  and  a  glass  and 
one-half  of  water.  Masticate  the  bread  thoroughly.  This 
should  be  removed  in  one  hour.  Pour  in  200  c.c.  of  water 
and  remove  this  as  the  lavage. 

An  objection  to  this  test  meal  (Ewald's)  is  the  presence 
of  a  certain  amount  of  lactic  acid  in  the  bread.  A  good  sub- 
stitute for  the  bread  is  one  Shredded  Wheat  Biscuit. 

Physical,  Chemical  and  Microscopical  Examination. 

A  physical,  chemical  and  microscopical  examination  should 
be  made  of  the  fasting  contents  and  the  test  meal  removed  in 
one  hour. 

Physical  Examination. 
Quantity. — 

Measure  amount  of  fasting  contents,  and  the  amount  after 
a  test  meal,  which  should  be  about  100  c.c,  if  200  or  300  c.c. 
either  motor  insufficiency  or  hypersecretion  is  probable.  Note 
proportion  of  fluid  in  the  total  quantity  of  contents,  the  food 
residue  should  be  about  one-fourth. 
(38) 


Gastric  Contents.  39 

Color. — 

Coffee  ground  appearance  suggests  cancer.  Reddish  color 
is  due  to  blood  and  suggests  ulcer.  Green  or  yellow  'color  is 
due  to  bile. 

Odor. — 

The  odor  of  butyric  acetic  and  lactic  acid  and  yeast  is 
characteristic  of  fermentative  changes  in  the  stomach. 

Mucous. — 

Large  amounts  suggest  chronic  gastritis.  Small  amounts 
occur  normally. 

Chemical  Examination. 

Qualitative  examination  should  be  made  for  the  following: 
Free  acids,  combined  hydrochloric  acid,  free  hydrochloric 
acid,  organic  acids   (lactic  acid),  pepsin,  rennin  and  blood. 

1.  Free  Acids. — 

Use  Congo  red  paper.  A  blue  color  indicates  the  presence 
of  free  acids. 

2.  Free  Hydrochloric  Acid. — 

Topfer's  Test. — Add  to  5  c.c.  of  gastric  contents  two  drops 
of  Topfer's  solution.  A  carmine  red  color  indicates  free  hy- 
drochloric acid. 

Gunzhurg's  Test. — Mix  a  drop  of  this  reagent  with  a 
drop  of  gastric  contents  in  a  porcelain  dish  or  on  a  glass  slide. 
Evaporate  slowly  over  a  flame.  A  bright  red  color  at  con- 
tact indicates  free  hydrochloric  acid. 

3.  Combined  Hydrochloric  Acid. — 

When  there  is  no  free  hydrochloric  acid  present  it  is  im- 
portant to  know  whether  there  is  achylia  gastrica  (no  free 
nor  combined  hydrochloric  acid)  or  merely  hypo-acidity 
(combined  hydrochloric  acid  being  present). 

Take  10  c.c.  of  gastric  contents.  Add  a  pinch  of  barium 
carbonate,  which  is  insoluble.  Evaporate  in  a  porcelain  dish 
to  dryness  and  fuse  at  a  low  red  heat. 


40  Diagnostic  Methods. 

If  hydrochloric  acid  combined  with  proteids  is  present,  the 
heat  will  liberate  the  hydrochloric  acid  and  the  chlorine  of 
the  hydrochloric  acid  will  unite  with  the  barium  of  the 
barium  carbonate  and  form  barium  chloride.  Allow  this  to 
cool  and  add  distilled  water  to  the  residue  of  the  porcelain 
dish.  "When  it  is  dissolved,  filter.  Divide  the  filtrate  into 
two  parts.  Add  to  one  part  a  iew  drops  of  a  saturated  solu- 
tion of  sodium  carbonate. 

A  precipitate,  which  is  barium  carbonate,  indicates  com- 
bined hydrochloric  acid  in  the  original.  The  other  part  of 
the  filtrate  should  be  used  as  a  control. 

4.  Organic  Acids. — 

Lactic. — Dilute  an  aqueous  solution  of  ferric  chloride  with 
water  to  a  faint  yellow  color.  Fill  two  test  tubes  about  one- 
third  full  with  this  solution.  Use  one  tube  as  a  control,  and 
to  the  other  add  5  drops  of  gastric  contents;  an  intensifica- 
tion of  the  yellow  color  indicates  lactic  acid. 

Uffelm,ann's  Test  for  Lactic  Acid. — Into  a  test  tube  pat 
about  y2  inch  depth  of  5  per  cent  carbolic  acid.  To  this  add 
one  drop  of  an  aqueous  solution  of  perchloride  of  iron,  a 
deep  amethj^st  color  results.  Dilute  this  ,with  distilled  water 
until  it  can  be  seen  through  readily.  Into  a  test  tube  ^^ 
filled  with  this  diluted  reagent  pour  5  to  8  drops  of  the  gas- 
tric juice.  The  amethyst  color  changes  to  a  canary  yellow 
in  the  presence  of  lactic  acid. 

5.  Pepsin. — 

Take  10  c.c.  of  unfiltered  stomach  contents  in  each  of  two 
tubes  and  to  each  tube  add  some  albumen  of  a  hard-boiled 
egg.  Add  to  one  of  the  test  tubes  an  equal  amount  of  .4  so- 
lution of  hydrochloric  acid,  and  to  the  other  an  equal  amount 
of  water.  No  free  hydrochloric  acid  should  be  present  at 
the  beginning  of  the  experiment.  Place  each  in  thermostat 
for  24  hours  and  note  the  digestion  of  the  egg  albumen,  which 
means  that  pepsin  is  present. 

6.  Rennin. — 

Take  10  c.c.  of  unfiltered  stomach  contents  and  neutralize 
to  litmus  by  adding  10  per  cent  sodium    hydrate    solution. 


Gastric  Contents.  41 

Take  10  c.c.  of  milk  and  boil  to  kill  bacteria.  Allow  this  to 
cool.  Add  5  c.c.  neutral  gastric  contents  to  the  10  c.c.  of 
milk  and  put  in  water  bath  at  body  temperature  for  30 
minutes.  A  curdling  of  the  milk  indicates  the  presence  of 
rennin.  It  is  well  to  take  varying  amounts  of  the  gastric 
contents,  as  this  will  indicate  the  quantity  of  the  ferment. 

7,     Blood.— 

A.  Giiaiac  Test. — Place  10  c.c.  of  gastric  contents  in  a 
test  tube  and  add  2  c.c.  of  glacial  acetic  acid  and  15  c.c.  of 
ether.  Insert  a  cork  and  shake  gently  for  several  minutes. 
After  the  ether  has  separated,  decant.  Add  to  the  etheral 
solution  10  drops  of  freshly  prepared  tincture  of  guaiac  and 
2  c.c.  of  hydrogen  peroxide.  A  blue  color  indicates  the  pres- 
ence of  blood. 

B.  The  following  chemical  test  may  also  be  used.  Place 
some  of  the  material  supposed  to  contain  blood  on  a  glass 
slide,  add  to  this  a  minute  crystal  of  sodium  iodide,  and  then 
two  drops  of  glacial  acetic  acid.  Cover  with  cover  glass  and 
warm  gently  over  flame  until  bubbles  appear.  If  blood  is 
present,  crystals  of  hemin  will  easily  be  seen  under  high  dry 
lens. 

Quantitative  Examination. 

Quantitative  examination  should  be  made  for  Free  Hydro- 
chloric Acid,  Total  Acidity,  and  Combined  Hydrochloric 
Acid. 

Free  Hydrochloric  Acid. — 

To  10  c.c.  of  unfiltered  gastric  contents  add  3  drops  of 
Topfer's  solution.  Titrate  with  decinormal  sodium  hydrate 
solution  until  the  disappearance  of  the  carmine  red  color. 
This  point  represents  the  neutralization  of  the  free  hydro- 
chloric acid  in  the  contents  used. 

To  estimate  the  quantity  of  free  hydrochloric  acid  multiply 
the  number  of  c.c.  of  the  decinormal  sodium  hydrate  solu- 
tion used  in  the  titration  by  10.  This  gives  the  amount  of 
free  hydrochloric  acid  in  100  c.c.  of  gastric  contents  in  terms 
of  decinormal  sodium  hydrate.     The  result  may  be  expressed 


42  Diagnostic  Methods. 

in  per  cent  of  hydrochloric  acid  if  the  above  quantity  is  mul- 
tiplied by  .00365,  i.  e.  the  quantity  of  hydrochloric  acid 
which  is  neutralized  by  1  c.c.  of  decinormal  sodium  hydrate. 
The  normal  quantitative  values  of  free  hydrochloric  acid 
vary  between  .07  and  .18  per  cent,  or  20  to  50  c.c.  of  deci- 
normal sodium  hydrate  per  100  c.c.  of  gastric  contents. 

Total  Acidity. — 

To  the  same  contents  in  which  the  free  hydrochloric  acid 
has  already  been  neutralized,  add  3  drops  of  a  1  per 
cent  alcohol  solution  of  phenolphthalein.  Continue  the  titra- 
tion with  decinormal  sodium  hydrate  solution  until  a  per- 
manent red  color  is  obtained.  This  represents  the  neutrali- 
zation of  all  the  acid  constituents  of  the  gastric  contents 
(free  mineral,  organic  acids  and  combined  acids). 

To  estimate  the  total  acidity  multiply  the  number  of  c.c. 
of  the  decinormal  sodium  hydrate  solution  used  from  the  be- 
ginning of  the  titration  up  to  this  point  by  10.  This  gives 
the  total  acidity  of  100  c.c.  of  gastric  contents  in  terms  of 
decinormal  sodium  hydrate.  The  result  may  be  expressed  in 
per  cent  hydrochloric  acid  by  multiplying  the  above  quan- 
tity by  .00365.  The  normal  quantitative  values  of  the  total 
acidity  vary  between  .15  and  .30  per  cent,  or  40  to  80  c.c. 
decinormal  sodium  hydrate  per  100  c.c.  of  gastric  contents. 

Combined  Hydrochloric  Acid. — 

To  10  c.c.  of  gastric  contents  add  3  drops  of  a  1  per  cent 
solution  of  phenolphthalein.  Titrate  with  decinormal  sodium 
hydrate  solution  until  a  pink  color  is  obtained  throughout. 
Read  off  from  the  burette  the  number  of  c.c.  of  decinormal 
solution  required.  Take  another  10  c.c.  of  the  gastric  con- 
tents and  add  3  or  4  drops  of  a  1  per  cent  solution  (aque- 
ous) of  alizarin  as  an  indicator.  Titrate  with  decinormal  so- 
dium hydrate  solution  until  the  yellow  color  has  disappeared 
completely  and  a  purple  color'  appears.  Read  off  from  the 
burette  the  number  of  c.c.  of  the  decinormal  sodium  hydrate 
solution  required.  Subtract  the  number  of  c.c.  required 
with  alizarin  as  an  indicator  from  the  number  required  with 
phenolphthalein  as   an   indicator,   and   multiply  by   10,   and 


Gastric  Go7itents.  43 

this  will  give  the  amount  of  combined  hydrochloric  acid  ex- 
pressed in  terms  of  decinormal  sodium  hydrate  solution. 
The  indicator,  phenolphthalein,  reacts  to  free  acids,  acid 
salts,  and  combined  acids,  but  the  indicator,  alizarin,  reacts 
only  to  free  acids  and  acid  salts,  but  not  combined  acids. 

Microscopical  Examination. 

This  should  be  done  in  all  fasting  contents,  which  should 
not  be  filtered.  Examine  for:  (a)  food  particles,  as  muscle 
fibers,  starch  cells,  starch  granules  and  fat  globules,  (b)  mu- 
cus, (c)  red  blood  cells,  (d)  leucocytes,  (e)  sarcinge,.  (f) 
yeast  cells,   (g)  bacteria,  as  Oppler-Boas  bacillus. 

Stomach  Contents  in  Disease. 

Gastric  Cancer. — 

Amount  varies  depending  on  whether  or  not  there  is  a 
stenosis. 

Blood  is  present  when  there  is  ulceration,  which  may  be 
early  or  late  in  the  disease.  The  color  of  the  stomach  con- 
tents is  not  changed  by  small  quantities  of  blood,  and  an  ade- 
quate chemical  examination  is  necessary  for  the  detection. 
If  much  blood  is  present,  and  remains  in  the  stomach  for  a 
time,  a  coffee  ground  appearance  is  given  to  the  stomach 
contents. 

In  about  80  per  cent  of  the  cases  there  is  no  free  hydro- 
chloric acid  present ;  however  when  a  malignant  growth  be- 
gins on  the  base  of  an  old  ulcer  the  hydrochloric  acid  may 
not  only  be  normal  in  quantity  but  even  excessive  in  amount. 

When  free  hydrochloric  acid  is  absent  there  is  usually  al- 
ways a  certain  amount  of  lactic  acid  present. 

Microscopically  one  often  finds  the  Oppler-Boas  bacillus 
when  lactic  acid  is  present,  and  red  blood  cells  may  also  be 
found. 

Gastric  Ulcer. — 

Seventy-five  per  cent  of  all  cases  show  the  presence  of 
blood,  which  may  be  in  macroscopical  amounts,  or  a  chemical 


44  Diagnostic  Methods. 

I 
examination  may  be  required  to   demonstrate  its  presence. 
Free  hydrochloric  acid  is  increased  in  about  half  the  cases, 
as  is  also  the  total  acidity.     Blood  may  be  present  in  feces. 

Gastric  Neurosis. — 

The  findings  are  variable.  Hydrochloric  acid  is  some- 
times increased  and  sometimes  diminished.  Pepsin  is  nor- 
mal. 

Chronic  Gastritis. — 

In  early  cases  hydrochloric  acid  may  be  increased.  It  is 
generally  diminished  in  well  marked  cases,  and  is  often  ab- 
sent in  advanced  cases.  When  absent  lactic  acid  is  present 
in  traces,  mucus  is  present  and  is  significant  of  the  disease, 
motility  and  absorption  is  generally  deficient. 

Achylia  Gastrica. — 

This  is  frequently  the  terminal  stage  of  chronic  gastritis. 
There  is  an  entire  absence  of  hydrochloric  acid,  and  a  very 
low  total  acidity.  A  small  amount  of  lactic  acid  may  be 
present.  The  motility  of  the  stomach  is  fairly  good.  This 
condition  is  often  associated  with  gastric  carcinoma  and  per- 
nicious anemia. 


CHAPTER  VI. 
BLOOD. 

Examination  of  a  Drop  of  Fresh  Blood. — 

Secure  a  drop  of  blood  on  a  cover  slip  and  drop  same  on 
a  slide  and  immediately  examine  microscopically.  The  slide 
and  cover  slip  must  be  absolutely  clean  to  enable  the  blood 
to  spread  in  a  very  thin  layer.  Note  size,  shape  and  color  of 
red  corpuscles.  Note  the  leucocytes  and  the  ameboid  move- 
ments of  the  polynuclear  variety.  Note  the  fibrin.  One  may 
examine  fresh  blood  for  the  malarial  parasite,  embryos  of 
filaria  sanguinis  hominis  and  the  trypanosoma  gambiense. 

Haemoglobin. — 

For  an  accurate  estimation  use  the  Sahli  apparatus.  The 
haemoglobin  is  expressed  in  percentage,  100  per  cent  being 
considered  as  the  normal. 

Estimation  of  Haemoglobin. — 

By  the  Use  of  the  Sahli  Hmnometer. — Fill  the  graduated 
tube  to  mark  10  with  N/10  hydrochloric  acid.  Fill  the 
pipette  up  to  the  mark  20  cu.  m.m.  with  blood.  This  is 
quickly  discharged  into  the  N/10  hydrochloric  solution. 
Shake  and  let  stand  for  one  minute.  Now  dilute  with  water 
until  color  matches  that  of  the  standard  solution.  The 
height  of  the  column  is  then  read.  This  gives  the  hsemo- 
globin  percentage. 

By  the  Talquist  Scale  of  Colons. — A  rather  large  drop  of 
blood  is  collected  on  one  of  the  squares  of  filter  paper  that  is 
supplied  in  the  book.  The  gloss  is  allowed  to  disappear,  and 
it  is  then  placed  under  the  perforation  in  one  of  the  red 
strips.  It  is  moved  until  the  color  of  the  drop  of  blood  cor- 
responds with  one  of  the  shades  of  red.     This  represents  the 

(45) 


46  Diagnostic  Methods. 

hgemoglobin  percentage  of  the  blood.     The  results  are  inex- 
act, but  suffice  for  rapid  bedside  work. 

Color  Index. — 

This  is  the  quotient  obtained  by  dividing  the  percentage  of 
haemoglobin  by  the  percentage  of  red  blood  corpuscles,  5,000,- 
000  red  cells  per  cu.  m.m.  being  considered  as  100  per  cent 
of  the  corpuscles.  Normally  the  color  index  is  about  one. 
When  the  index  is  less  than  one  it  indicates  that  the  average 
corpuscle  is  poor  in  coloring  matter,  whereas  with  a  high 
color  index  the  corpuscles  are  rich  in  hsemoglobin. 

Making  a  Blood  Smear. 

A  blood  smear  for  purposes  of  staining  is  made  on  either 
cover  slip  or  slide.  For  delicate  and  accurate  work  the  for- 
mer is  superior,  but  for  all  practical  purposes  the  latter  suf- 
fices. 

The  slide  or  cover  slip  intended  for  the  smear  should  be 
first  thoroughly  cleansed  with  soap  and  water,  rinsed  in 
clear  water,  and  finally  in  about  50  per  cent  alcohol.  It 
should  be  rubbed  dry  with  a  clean  cloth,  care  being  used  not 
to  touch  the  flat  surface  with  the  fingers,  but  only  the  sides. 

Cleanse  the  lobe  of  the  ear  or  end  of  the  finger  with  soap 
and  water,  and  then  alcohol.  Usually  alcohol  alone  will  suf- 
fice. Wipe  dry  and  pierce  with  a  surgical  needle.  Wipe 
away  the  first  few  drops  of  blood.  Touch  the  center  of  the 
cover  glass  against  the  top  of  the  blood  drop  and  immediately 
drop  this  on  top  of  a  clean  cover  slip.  About  the  time  the 
blood  ceases  to  spread  draw  them  apart,  but  keep  their  sur- 
faces parallel. 

A  smear  may  be  made  on  a  clean  slide  by  getting  a  drop 
near  one  end  and  with  another  slide  gradually  drawing  this 
drop  over  the  slide. 

Blood  Counting. 

For  the  purpose  of  counting  erythrocytes  or  leucocytes,  a 
counting  chamber  and  pipette  are  required.  The  pipettes  for 
red  cells  and  white  cells  are  graduated  differently  in  order 


Blood, 


47 


to  make  the  dilution  satisfactory  for  the  count,  the  red  cells 
requiring  much  greater  dilution  than  the  white  cells.  The 
pipette  for  the  red  cells  is  marked  0.5  at  half  the  distance  of 
the  capillary  tube  and  1  at  the  upper  end  of  the  tube.  Above 
the  bulb  is  the  mark  101.  If  the  blood  is  drawn  only  to  .5, 
as  is  customary,  and  then  the  diluting  fluid  to  the  mark  101, 
then  the  red  cells  have  a  dilution  of  1  to  200.  If  the  blood  is 
drawn  to  1  and  the  diluting  fluid  to  101,  then  the  dilution  is 
1  to  100. 

The  pipette  for  the  leucocytes  is  marked  0.5  at  half  the 
distance  of  the  capillary  tube,  and  1  at  the  upper  part  of  the 

BLOOD-COUNTING    CHAMBERS. 


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Zappert-Ewing. 


Thoma. 


capillary  tube.  Above  the  bulb  is  the  mark  11.  If  the  blood 
is  drawn  only  to  .5,  as  is  customary,  and  then  the  diluting 
fluid  to  the  mark  11,  then  the  leucocytes  have  a  dilution  of 
1  to  20.  If  it  is  drawn  to  1  and  the  diluting  fluid  to  11,  then 
the  dilution  is  1  to  10. 


48  Diagnostic  Methods. 

The  counting  chamber  consists  of  a  thick  glass  slide,  on 
the  center  of  which  is  mounted  a  small  circular  glass  disc 
which  is  ruled  according  to  either  Thoma,  Tiirck,  or  Zappert- 
Ewing.  This  circular  ruled  disc  is  surrounded  by  a  square 
glass  table  mounted  also  on  the  slide.  The  glass  table  is  ex- 
actly 0.1  m.m.  above  that  of  the  ruled  disc.  A  moat  sepa- 
rates the  table  from  the  ruled  disc. 

The  disc  ruled  according  to  Thoma  is  as  follows :  This  con- 
sists of  five  square  millimeters.  The  central  square  milli- 
meter, which  is  used  for  counting  the  erythrocytes,  is  subdi- 
vided into  400  small  squares.  By  means  of  double  lines  these 
smallest  squares  are  grouped  into  blocks  of  25,  a  convenient 
unit  to  employ  in  counting  the  red  cells.  For  the  leucocytes 
all  five  square  millimeters  are  counted  and  the  average  is  one 
square  millimeter  estimated. 

The  rulings  according  to  Tiirck  and  Zappert-Ewing  are 
similar  to  that  of  Thoma,  but  in  the  latter  two  there  are  nine 
square  millimeters  instead  of  five.  These  latter  two  differ  in 
ruling  of  the  four  corner  squares.  For  the  red  count  only 
the  central  square  millimeter  with  its  400  small  squares  is 
used,  while  for  the  leucocytes  all  nine  are  counted  and  the 
average  taken. 

The  counting  chamber  ruled  according  to  Tiirck  is  the 
most  serviceable  and  is  the  one  the  author  recommends. 

1.    Red  Corpuscles. — 

Draw  the  blood  into  the  blood  pipette  up  to  the  mark 
.5  and  dilute  with  Hayden's  solution  up  to  the  mark  101. 
Mix  thoroughly.  Blow  out  two  or  three  drops,  then  place  a 
drop  in  the  center  of  the  ruled  glass  piece  of  the  counting 
slide,  and  gently  place  on  the  cover  slip.  If  a  small  amount 
passes  out  into  the  moat  it  will  not  matter,  but  it  should 
not  pass  out  under  the  cover  slip,  as  this  raises  it  to  a  greater 
distance  than  .1  of  a  millimeter. -^  Examine  for  Newton's  rings. 
Count  'the  red  corpuscles  in  25  small  squares  at  each  of  the 
four  corners  of  the  central  ruled  square,  then  multiply  by 
four,  then  by  ten,  and  finally  by  the  dilution  200.  Repeat 
the  count  and  take  the  average.     In  making  the  count,  cells 


Blood.  49 

are  often  seen  in  the  position  across  the  lines  so  the  rule  is 
to  count  the  cells  crossing  the  left  and  lower  lines  and  not 
counting  those  touching  the  upper  and  right  lines.  This 
count  gives  the  number  of  red  blood  cells  in  a  cubic  milli- 
meter of  blood. 

2.    White  Corpuscles. — 

Draw  the  blood  into  the  blood  pipette  up  to  the  mark  .5 
and  dilute  with  1  per  cent  acetic  acid  up  to  the  mark  11.  Mix 
thoroughly.  Blow  out  two  or  three  drops,  then  place  one 
drop  in  the  center  of  the  ruled  glass  piece  of  the  counting 
.slide,  and  gently  place  on  cover  slip.  If  a  small  amount 
passes  out  into  the  moat  it  will  not  matter,  but  it  should  not 
pass  out  under  the  cover  slip,  as  this  raises  it  to  a  greater  dis- 
tance than  .1  of  a  millimeter.  Examine  for  Newton's  rings. 
Count  the  leucocytes  in  the  several  square  millimeters,  and 
get  the  average  in  one.  Multiply  this  by  10,  then  by  20.  Re- 
peat this  and  get  the  average. 

Cleaning  the  Blood-counting  Apparatus. — 

(a)  Covnting  Chamher. — Clean  this  with  water  only.  A 
little  soap  may  be  used.  Never  use  alcohol,  ether  or  other 
solvent,  as  the  cement  by  which  the  ruled  disc  is  fastened  to 
the  slide  may  be  dissolved. 

(b)  Pipettes. — Always  clean  immediately  after  using. 
The  following  steps  should  be  employed:  (1)  Blow  out  con- 
tents. (2)  Draw  up  into  it  distilled  water  and  blow  it  out. 
(3)  Repeat  this.  (4)  Draw  up  95  per  cent  alcohol  once  or 
twice  and  blow  it  out.  (5)  Repeat  with  ether,  the  last  time 
removing  the  rubber  tubing  and  blowing  out  through  the 
large  end. 

Method  of  Staining  Blood  Smears. — 

1.  Let  the  specimen  dry  in  the  air. 

2.  Cover  well  with  Wright's  stain  for  one  minute. 

3.  Add  distilled  water,  drop  by  drop,  until  a  delicate 
metallic  scum  appears  on  the  surface,  usually  3  drops. 

4.  Leave  this  dilute  stain  on  for  2  minutes. 


50  Diagnostic  Methods. 

5.  Wash  in  distilled  water  about  5  seconds,  or  until  the 
preparation  has  a  pinkish  color. 

6.  Dry  quickly,  mount  and  examine. 

Examine  the  red  blood  cells  and  note  variations  in  size 
(mikrocytes  and  makrocytes),  and  shape  (poikilocytes). 
Note  loss  of  color  (achromia).  Stippling;  i.  e.,  appearance 
of  granules  in  the  cell.  Polychromatophilia.  Note  the  ap- 
pearance of  blasts,  either  normoblasts  or  megaloblasts. 

Examine  the  white  blood  cells  (leucocytes).  Make  a  dif- 
ferential count  by  counting  at  least  200  white  corpuscles. 

Note  the  number  and  percentage  of: 

1.  Polynuclear  basophiles. 

2.  Polynuclear  neutrophiles. 

3.  Polynuclear  eosinophiles. 

4.  Small  lymphocytes. 

5.  Large  lymphocytes. 

6.  Large  mononuclears. 

7.  Transitional. 

Examine  for  myelocytes  (neutrophilic,  eosinophilic,  or 
basophilic). 

Examine  the  blood  plates.  These  appear  with  Wright's 
stain  as  round  or  oval  bodies  stained  purplish.  They  are 
often  found  in  clumps  and  are  about  one-third  the  size  of  a 
red  blood  cell. 

Examine  for  parasites.  The  malarial  parasites  will  be 
stained  blue,  are  found  in  the  red  cells,  and  are  seen  to  con- 
tain brownish  granules.  Collections  of  pigment  are  often 
seen  in  the  white  corpuscles.  Look  for  crescents  or  ovoid 
bodies,  indicating  sestivoautumnal  malaria.  Crescents  are 
stained  pale  blue,  have  pigment  granules  in  center  and  the 
remnant  of  a  red  cell  about  them. 

Widal  's  Serum  Reaction. —    , 

Use  a  bouillon  culture  of  bacillus  typhosus  12  to  24  hours 
old.  Examination  by  high  dry  lens  should  show  the  bacilli 
in  active  motion  and  unclumped.  A  growth  on  agar  agar 
about  24  hours  old  may  also  be  used. 


Blood.  51 

Get  the  blood  from  the  patient  in  a  glass  tube  drawn  out 
at  both  ends  into  a  capillary  tube.  Usually  5  to  10  drops  or 
less  are  sufficient.  Centrifugalize  to  throw  corpuscles  to  bot- 
tom. Drop  9  drops  of  physiological  salt  solution  into  a  small- 
size  glass  tube,  and  19  drops  into  another.  Add  a  drop  of 
the  serum  to  each  tube  and  mix  thoroughly.  Place  a  drop  of 
this  diluted  serum  from  each  tube  on  two  cover  slips  and  add 
a  platinum  loop  of  typhoid  bacilli  grown  on  bouillon  to  each 
drop.  This  gives  a  dilution  of  1  to  20,  and  1  to  40  respect- 
ively. Place  cover  slip  on  a  hanging  glass  slide  and  examine 
microscopically  with  a  high  power  dry  lens. 

The  serum  reaction  is  regarded  as  positive  when  there  is 
complete  clumping  of  the  bacilli  and  absolute  cessation  of 
motility.  The  time  limit  for  the  test  is  one  hour,  although 
the  agglutination  often  occurs  within  a  few  minutes.  A  re- 
action at  1  to  20  is  very  suggestive,  while  a  reaction  at  1  to 
40  can  be  accepted  as  conclusive  evidence  of  typhoid  infec- 
tion. 

Another  method  of  securing  the  blood  is  by  getting  a  large 
drop  on  a  glass  slide  and  extracting  the  blood  with  water. 
Place  5  or  6  drops  of  water  on  a  large  drop  of  blood  and  let 
stand  for  15  minutes.  Then  gently  stir  with  a  platinum  loop, 
but  do  not  mix  up  the  cells  and  fibrin  in  the  extract.  Take 
one  platinum  loop  full  of  this  extract  and  add  it  to  the  same 
quantity  of  a  12-hour  bouillon  culture  of  typhoid  bacilli. 
This  gives  an  approximate  dilution  of  1  to  40.  Examine  this 
for  agglutination. 

Blood  Culture. — 

This  should  be  done  in  all  cases  of  suspected  septicemia. 
The  diagnosis  of  typhoid  fever  is  earliest  made  by  the  detec- 
tion of  typhoid  bacilli  in  the  blood.  The  best  culture  media 
for  the  typhoid  and  colon  bacilli  is  sterilized  ox  bile,  but  for 
cocci,  glucose  bouillon  and  glucose  agar  is  the  most  suitable. 

In  a  case  of  suspected  typhoid  fever  remove  a  few  c.c.  of 
blood  from  the  vein  of  the  arm  and  inject  1  c.c.  in  several 
test  tubes  containing  about  5  c.c.  each  of  sterilized  ox  bile. 
Shake  gently,  place  in  incubator  for  24  to  36  hours,  then  in- 


52  Diagnostic  Methods. 

oculate  a  bouillon  and  agar  tube,  and  after  24  to  36  hours  note 
the  presence  or  absence  of  a  growth. 

In  a  case  of  suspected  septicemia  remove  a  few  c.c.  of 
blood  in  the  same  manner  as  in  the  above,  and  inject  2  c.c. 
each  in  2  or  3  bottles  or  flasks  of  fresh  glucose  bouillon  which 
contains  about  30  c.c.  Also  inject  2  c.c.  in  melted  glucose 
agar  whose  temperature  is  not  more  than  42°.  Shake  gently 
in  either  case.  Allow  the  agar  to  solidify,  then  place  in  in- 
cubator at  37°  C.  for  24  to  48  hours  and  note  the  presence  or 
absence  of  a  growth.  The  culture  media  may  be  placed  in 
six-ounce  rectangular  shaped  bottles. 

Changes  in  the  Blood  in  Various  Diseases. 

Pernicious  Anemia. — 

Number  of  red  blood  cells  usually  greatly  diminished. 
The  percentage  of  haemoglobin  also  diminished,  but  not  to 
the  same  extent  as  the  number  of  red  blood  cells.  Color  in- 
dex is  therefore  high,  about  1.  or  1+.  Very  many  macro- 
cytes  (usually  well  stained),  and  many  poikilocytes,  are  pres- 
ent. Often  there  is  seen  granular  degeneration,  also  poly- 
chromatophilia.  Variable  number  of  nucleated  red  blood 
cells,  the  predominating  variety  being  the  megaloblasts,  al- 
though normoblasts  are  often  seen.  Leucocytes  in  the  ma- 
jority of  cases  are  somewhat  diminished  with  relative  in- 
crease of  the  lymphocytes. 

Acute  Lymphatic  Leukemia. — 

Number  of  red  blood  cells  more  or  less  diminished.  The 
percentage  of  haemoglobin  also  diminished  and  more  in  extent 
than  the  red  blood  cells.  This  gives  a  low  color  index.  Very 
often  nucleated  red  blood  cells,  which  are  chiefly  normo- 
blasts, are  seen.  Leucocytes  are  more  or  less  markedly  in- 
creased, from  50,000  to  250,000  per  cu.  m.m.  The  predom- 
inating cell  is  the  lymphocyte,  the  number  of  which  fre- 
quently exceeds  80  per  cent,  the  majority  being  the  large 
lymphocyte. 


Blood.  53 

Chronic  Lymphatic  Leukemia.— 

Number  of  red  blood  cells  diminished.  The  percentage  of 
haemoglobin  is  diminished  to  a  greater  extent  than  the  num- 
ber of  red  blood  cells.  The  color  index  is  therefore  low.  Nu- 
cleated red  cells  are  not  so  often  seen  as  in  the  acute  variety, 
but  they  are  frequently  found.  Leucocytes  are  very  much 
increased,  the  average  being  about  350,000  per  cu.  m.m.  The 
variety  especially  involved  is  the  small  lymphocytes,  more 
than  90  per  cent  being  of  this  variety. 

Spleno-Myelogenous  Leukemia. — 

Number  of  red  blood  cells  more  or  less  diminished.  The 
percentage  of  haemoglobin  is  also  diminished,  and  to  a  greater 
extent  than  the  red  blood  cells.  The  color  index  is  therefore 
low.  Many  poikilocytes,  stipple  cells,  macrocytes  and  micro- 
cytes  are  present.  Very  many  nucleated  red  cells  are  pres- 
ent. These  are  chiefly  normoblasts,  but  megaloblasts  are 
also  found.  Leucocytes  are  very  much  increased  in  number, 
on  an  average  of  350,000  to  a  cu.  m.m.  of  blood,  but  the  num- 
ber runs  from  150,000  per  cu.  m.m.  to  600,000  or  700,000. 
The  type  chiefly  involved  is  the  myelocyte,  40  to  60  per  cent 
of  the  leucocytes  being  of  this  variety.  The  neutrophilic, 
eosinophilic  and  basophilic  myelocytes  are  all  present,  but  the 
largest  per  cent  is  of  the  neutrophilic  variety. 

Chlorosis. — 

The  hgemoglobin  is  markedly  diminished;  the  number  of 
red  blood  cells  very  slightly  so  and  sometimes  not  at  all. 
Color  index  is  always  low.  Achromia  is  marked,  poikilo- 
cytes, stipple  cells,  and  occasionally  a  few  normoblasts.  The 
leucocytes  are  not  affected  as  to  the  number.  There  is  usu- 
ally a  slight  relative  increase  in  the  lymphocytes.  This  con- 
dition occurs  at  about  the  age  of  puberty  in  young  girls  who 
are  very  nervous. 

Splenomegaly  or  Splenic  Anemia. — 

A  condition  characterized  by  enlargement  of  the  spleen, 
an  anemia  of  a  secondary  type,  without  leucocytosis  or  lym- 
phatic enlargement,  and  a  gradual  downward  course.  If  there 
is,  in  addition  to  the  enlarged  spleen,  cirrhosis  of  the  liver, 
jaundice  and  ascites,  the  condition  is  called  Banti's  disease. 


CHAPTER   VII. 

SEROUS  FLUIDS. 

This  includes  both  transudates  and  exudates.  Transudates 
are  non- inflammatory.  The  specific  gravity  is  1008  to  1018, 
with  only  a  few  cells  and  a  small  amount  of  albumen ;  i.  e., 
.2  to  2  per  cent.  Exudates  are  inflammatory  in  origin.  The 
specific  gravity  is  1018  to  1026,  larger  number  of  cells  and 
a  greater  abundance  of  albumen,  2  to  6  per  cent. 

Serous  Fluids. 

The  Serous  Fluids  Are :  1.  Pleural.  2.  Peritoneal.  3.  Peri- 
cardial. 4.  Cerebrospinal.  In  examination  of  serous  fluids 
the  methods  that  apply  to  one  will  apply  to  all. 

Physical  Examination. — 

Note  the  color,  turbidity,  and  take  the  specific  gravity. 
Note  the  amount  of  fibrin  or  clot,  take  reaction. 

Chemical  Examination. — 

Qualitative  and  Quantitative  tests  for  albumen.  (See  urine 
for  tests.) 

Cytodiagnosis. — 

This  is  important  as  a  diagnostic  method  and  consists  in 
a  differential  count  of  the  cells  in  a  transudate  or  exudate. 
The  following  should  be  carried  out : 

1.  Place  fluid  in  centrifuge  tubes  and  centrifugalize  for- 
3  minutes. 

2.  Pour  off  supernatant  fluid. 

3.  Make  smear  from  sediment  in  same  manner  as  blood 
smear. 

4.  Let  this  dry  in  the  air. 

5.  Cover  the  slip  with  Wright's  stain  for  45  seconds  and 
then  add  3  drops  of  water  and  let  remain  for  2  minutes. 

(54) 


Serous  Fluids.  55 

6.  Wash  rapidly  in  distilled  water. 

7.  Qnickly  blot  dry,  using  filter  paper. 

8.  Mount  and  examine  with  an  oil-immersion  lens,  and 
count  the  different  types  of  cells. 

A  predominance  of  polymorphonuclear  leucocytes  points 
to  an  acute  infection. 

A  predominance  of  lymphocytes  usually  means  tubercu- 
losis, but  may  mean  parasyphilis  or  cerebrospinal  syphilis. 

A  scarcity  of  cells,  with  a  predominance  of  endothelial 
cells,  indicates  a  transudation. 

Carcinoma  of  the  serous  membrane  shows  a  predominance 
of  endothelial  cells,  but  with  large  numbers  of  lymphocytes 
and  red  blood  cells. 

Bacteria  in  Serous  Fluids. — 

Pour  a  few  c.c.  of  the  fluid  into  a  flask  of  nutrient  bouillon. 
Incubate  for  24  to  36  hours  and  then  make  smear  on  cover 
slip  and  stain  with  Loffler's  methylene  blue  or  Gram's  stain. 
The  technique  of  these  staining  processes  has  already  been 
given. 

Make  smear  also  as  in  the  method  for  cytodiagnosis  and 
stain  with  Loffler's  blue  and  Gram's  stain.  In  this  way  bac- 
teria are  found. 

Total  Cell  Count  of  Serous  Fluids. — 

Draw  up  to  the  mark  I  in  the  white  cell  pipette  a  3  or  4 
per  cent  solution'  of  glacial  acetic  acid  tinged  slightly  with  a 
solution  of  gentian  violet.  Now  draw  up  the  serous  fluid  to  the 
mark  II.  Shake  well,  and  blow  out  first  2  or  3  drops.  Place  a 
drop  on  the  center  of  the  blood  counting  chamber,  gently  place 
on  cover  slip,  examine  for  Newton's  rings,  count  the  cells  in 
the  different  square  millimeters  on  the  counting  chamber.  Take 
the  average  in  one  square  m.m.  Take  1/10  of  this  and  add 
back  to  the  number.  Now  multiply  by  10.  This  gives  total 
number  of  cells  in  cubic  m.m.  of  the  fluid.  In  spinal  fluid 
the  number  is  normally  from  2  to  10.  In  acute  infections  of 
the  meninges  the  number  may  run  up  into  the  thousands. 
In  tuberculous  meningitis  the  number  runs  from  150  to  250 
per  cu.  m.m. 


56  Diagnostic  Methods. 

In  parasyphilitic  lesions  and  cerebrospinal  lues  the  num- 
ber runs  from  75  to  150  per  cu.  m.m.  In  the  latter  two  dis- 
eases there  is  a  high  percentage  of  lymphocytes,  while  in  the 
first  there  is  a  high  percentage  of  polymorphonuclear  neu- 
trophiles. 

NogucM's  Butyric  Acid  Test  for  increase  in  the  globulin 
content  of  the  cerebrospinal  fluid.  This  test  is  based  upon 
the  observation  that  in  syphilitic  and  parasyphilitic  affec- 
tions of  the  central  nervous  system  the  globulin  content  is 
increased. 

The  test  is  as  follows : 

Take  .15  c.c.  of  the  meningeal  fluid,  absolutely  free  from 
blood,  and  add  to  it  .5  c.c.  of  10  per  cent  solution  of  butyric 
acid  in  normal  saline.  Boil  this  a  few  seconds  over  a  flame, 
then  quickly  add  .1  c.c.  normal  sodium  hydrate  solution  and 
boil  for  a  few  seconds  longer.  In  the  presence  of  an  in- 
creased globulin  content  a  granular  or  flocculent  precipitate 
appears.  This  gradually  settles  to  the  bottom  of  the  tube. 
Usually  2  hours  is  given  for  the  appearance  of  this  gran- 
ular precipitate. 

Technique  for  the  Performance  of  Lumbar  Puncture. 

Locate  the  intervertebral  space  on  a  line  with  the  crest  of 
the  ilium.  This  is  usually  the  space  between  the  third  and 
fourth  lumbar  vertebra.  Cleanse  with  soap  and  water  an 
area  about  the  size  of  the  hand.  Rub  this  area  with  alcohol, 
and  then  it  may  or  may  not  be  painted  with  tincture  of  iodine. 
Have  patient  on  left  side  near  edge  of  bed,  with  head  and 
shoulders  slightly  elevated  on  a  pillow,  and  legs  flexed  well 
at  the  hips.  "With  a  sterile  lumbar  puncture  needle,  6  to  8 
centimeters  in  length,  enter  as  near  the  center  of  the  space 
between  the  spinous  processes  of  the  third  and  fourth  lum- 
bar vertebrae  as  possible.  (The  author  prefers  to  enter  in 
the  mid  line,  but  many  others  prefer  to  enter  about  1/5  to 
2/5  of  an  inch  to  the  right  or  left  of  the  mid  line.)  Pass  the 
needle  about  the  distance  of  4  centimeters  with  point  inclined 
slightly  toward  the  head  and  if  it  strikes  bone  withdraw  a 


Serous  Fluids.  '    57 

short  distance  and  change  slightly  the  direction  of  the  point 
of  the  needle,  and  continue  this  nntil  you  feel  it  pass 
the  dense  dura  mater  into  the  spinal  subarachnoidean  space. 
Withdraw  the  stilette  and  the  spinal  fluid  will  immediately 
begin  to  drop  out  in  rapid  intermittent  drops.  If  pressure 
is  very  much  increased  it  may  escape  in  a  stream.  The  fluid 
should  be  collected  in  sterile  test  tubes. 


CHAPTER  VIII. 
INTESTINAL   CONTENTS. 

A  Macroscopic,  Chemical  and  Microscopic  Examination  of 
the  stools  should  be  made  whenever  intestinal  trouble  is  sus- 
pected. Especially  is  this  true  in  the  South. 

The  examination  of  the  stools  is  very  much  simplified  if 
the  patient's  diet  is  restricted  for  two  or  three  days  before. 
The  diet  should  consist  of  milk,  toast,  gruel,  eggs,  oatmeal, 
butter,  rare  steak  and  potatoes.  '  If  this  is  not  done  then  ask 
the  patient  what  he  has  been  taking  for  the  past  two  or  three 
days. 

Macroscopic  Examination. 

.Note  the  color,  quantity,  frequency,  consistency,  odor,  and 
presence  of  mucus,  blood,  pus,  curds,  round  worms,  hook 
worms,  segments  of  tape  worms,  etc. 

Color. — 

The  normal  brown  color  is  due  to  hydrobilirubin.  Infants' 
stools  are  normally  bright  or  golden  yellow.  The  color  of 
the  stools  varies  with:  (a)  Food — light  with  milk  or  bread, 
dark  with  blackberries,  red  with  wine  and  exclusive  meat 
diet,  etc.,  green  with  green  vegetables,  (b)  Drugs — green 
after  administration  of  calomel,  black  after  bismuth  sub- 
nitrate  and  iron,  (c)  Blood — if  from  stomach  or  duodenum, 
tarry  stools;  if  from  colon  or  rectum,  bright  red.  (d)  Bile 
— clay-colored  from  diminished  secretions,  obstruction  to  flow 
of  bile,  and  from  unabsorbed  fat.  (e)  The  green  color  of 
stools  is  pathological,  and  is  due  to  the  presence  of  bilirubin. 

Quantity. — 

This  depends  on  amount  and  character  of  diet,  and  habits 
of  patient. 

Frequency. — 

Stools  may  be  numerous  but  without  fsecal  material.     Fre- 
(58) 


Intestinal  Contents.  59 

queiit  stools  that  come  from  colon  are  usually  small;  if  from 
small  intestines,  usually  large. 

Consistency. — 

This  depends  on  how  long  the  faeces  has  remained  in  the 
rectum.    Frothy  stools  indicate  intestinal  fermentation. 

Odor. — 

This  is  important  in  infants.  Normally  it  is  slightly  sour, 
foul  in  proteid  putrefaction,  sour  in  acid  fermentation,  odor- 
less in  cholera  infantum. 

Mucus. — 

This  is  usually  indicative  of  inflammation  of  the  large  in- 
testines. If  it  comes  as  a  coating  to  the  fseees,  or  as  mem- 
branous flakes,  shreds  or  gelatinous  clumps,  it  is  from  the 
large  intestines.  If  it  is  intimately  mixed  with  the  stools,  it 
is  from  the  small  intestines. 

Blood.— 

See  under  heading  of  "Color." 

Pus.— 

If  in  large  quantities  is  due  to  an  abscess  rupturing  into 
intestines,  or  to  ulcerative  colitis.  If  leucocytes  come  from 
above  coecum  they  will  be  digested,  and  only  the  nucleus 
will  be  seen. 

Curds. — 

These  are  often  seen  in  infants'  stools  and  are  an  indica- 
tion of  imperfect  proteid  digestion. 

The  stools  should  always  be  examined  also  for  worms  or 
their  segments.  This  is  best  done  by  taking  a  portion  of  the 
fieces-  and  adding  a  little  water  until  the  stool  is  a  thick 
liquid,  at  the  same  time  mixing  the  two  together  with  a  glass 
rod  or  pestle,  then  place  on  a  dark  glass.  Note  also  the  pres- 
ence of  mucus  or  undigested  food. 


60  Diagnostic  Methods. 

Chemical  Examination. 

Take  reaction,  examine  for  blood  and  bile. 

Blood  (occult). — 

In  performing  this  test  it  is  best  to  withdraw  meat  from 
the  diet  fop:*  3  days  beforehand,  as  muscle  fibers  give  a  posi- 
tive reaction  for  blood. 

Guaiac  Test. — Take  about  5  c.c.  of  stool  made  liquid  with 
water  unless  already  in  a  liquid  state.  Add  2  c.c.  of  glacial 
acetic  acid.  Shake  thoroughly  and  let  it  stand  for  5  min- 
utes. 

In  another  test  tube  take  pinch  of  powdered  gum  guaiac 
and  add  to  it  5  c.c.  of  95  per  cent  alcohol,  and  let  this  stand 
5  minutes.  Filter.  This  makes  tincture  of  guaiac.  In  the 
test  tube  containing  the  stools  and  acetic  acid  add  equal 
amount  of  ether  and  invert  tube  carefully  several  times. 
Decant  the  ether.  Add  to  the  ether  extract  tincture  of 
guaiac  and  hydrogen  peroxide  about  3  c.c.  Shake,  and  if 
you  get  a  blue  color  it  indicates  the  presence  of  blood. 

Benzidine  Test. — To  a  small  amount  of  the  faeces  is 
added  an  equal  amount  of  water.  Take  3  or  4  c.c.  of  this 
and  add  to  it  2  or  3  c.c.  of  alcoholic  solution  of  benzidine 
(made  up  by  saturating  95-  per  cent  alcohol  with  benzidine, 
using  some  heat,  then  filter).  Now  add  1  or  2  c.c.  of  hydro- 
gen peroxide  and  a  few  drops  of  acetic  acid.  In  the  pres- 
ence of  blood  an  intense  green  color  develops.  Occasionally 
a  light  blue  tinge.    This  test  is  extrepiely  delicate. 

Bile  (hydro-bilirubin). — 

Make  the  stool  liquid  by  addition  of  water  unless  already 
in  a  nearly  liquid  state.  Take  about  20  c.c.  of  this  mixture 
and  to  it  add  20  c.c.  of  a  concentrated  aqueous  solution  of 
corrosive  sublimate.  Shake  well  and  set  aside  for  12  to  24 
hours.  Any  facal  particles  that  contain  hydro-bilirubin  are 
colored  red,  and  all  particles  with  bilirubin  assume  a  green- 
ish shade.  This  test  is  also  of  value  when  you  wish  to  tell 
whether  pale  stools  contain  a  large- amount  of  fat,  or  is  due 
to  the  absence  of  bile  pigments. 


Intestinal  Contents.  61 

Microscopic  Examination. 

This  includes  food  particles,  epithelial  cells,  pus  cells, 
blood  corpuscles,  bacteria,  ova  and  larvae  of  parasites. 

The  microscopic  examination  is  rendered  much  easier  if  a 
portion  of  the  feeces  is  made  liquid  by  the  addition  of  wa- 
ter, then  filtered  through  one  layer  of  gauze  and  centrifugal- 
ized  for  a  minute.  Pour  off  the  water  and  add  more  and  mix 
thoroughly  with  a  glass  rod.  Centrifugalize  for  one-third 
minute  and  again  pour  off  the  fluid.  Repeat  this  a  second 
time.  Now  with  a  pipette,  get  the  part  from  the  bottom  of 
the  centrifugal  tube,  place  this  on  a  slide  and  cover  with 
cover  glass.  This  method  is  very  useful  when  looking  for 
ova  of  intestinal  parasites. 

1.  Food  Particles. — 

Examine  for  muscle  fibers,  starch  granules,  fat  droplets 
and  fatty  acid  needles,  which,  if  present,  indicate  defective 
digestion  of  either  proteid,  carbohydrates  or  fats.  The  ad- 
dition of  Lugol's  solution  will  color  starch  granules  blue 
and  so  enable  one  to  identify  them.  Other  things  present 
of  little  importance  are  vegetable  fibers,  vegetable  cells, 
starch  cells,  with  or  without  granules. 

2.  Epithelial  Cells. — . 

These  originate  from  the  walls  of  the  alimentary  canal. 
They  are  of  no  importance  beyond  their  recognition. 

3.  Pus  Cells.— 

If  intimately  mixed  with  stools  they  are  from  high  up  the 
intestinal  canal.  If  only  observed  microscopically  they  in- 
dicate a  catarrhal  or  slight  ulcerative  condition. 

4.  Blood  Corpuscles. — 

This  is  best  recognized  by  the  chemical  test. 

5.  Bacteria. — 

The  only  one  of  practical  importance  is  the  bacillus  tuber- 
culosis. The  method  is  as  follows :  Make  a  portion  of  the 
stool  fluid  with  water.  Take  12  c.c.  of  this  and  centrifugal- 
ize for  3  minutes.     All  the  bacteria  remain  in  the  super- 


62  Diagnostic  Methods. 

natant  fluid.  Pour  off  this  fluid  and  add  equal  amount  of 
95  per  cent  alcohol,  which  changes  the  specific  gravity  to 
that  lower  than  the  bacteria.  Centrifugalize  a  second  time 
and  this  throws  down  the  bacteria.  Pour  off  the  superna- 
tant fluid  and  then  make  a  thin  smear  of  the  sediment  on  a 
slide  and  stain  in  the  usual  method  for  the  bacillus  tuber- 
culosis. 

6.    Ova  of  Intestinal  Parasites. — 

It  is  very  important  to  recognize  ova  of  the  various  in- 
testinal parasites.  The  ova  most  commonly  found  in  the 
fffices  are  ova  of  the  following:  Oxyuris  vermicularis,  as- 
caris  lumbricoides,  trichocephalus  dispar,  uncinaria,  tsnia 
saginata,  taenia  nana,  bothriocephalus  latus,  and  taenia  so- 
lium. 

1.  Ova  of  Oxyuris  Vermicularis  are  often  not  found  in  the 
fseces.  They  are  oval  with  rounded  end  and  flattened  on  one 
side.  In  order  to  make  a  more  accurate  test  for  ova  of  this 
parasite,  either  scrape  the  mucous  membrane  of  the  rectum 
for  material  to  examine  microscopically,  or  give  a  cathartic 
and  examine  the  fluid  discharge. 

2.  Ova  of  Ascaris  Lumbricoides. — They  are  oval  in  shape 
and  brown  or  yellow  from  bile.  The  protoplasm  is  not  seg- 
mented and  is  granular,  and  margin  is  uneven  or  wavy. 

3.  Ova  of  Trichocephalus  Dispar. — They  are  oval,  yellow- 
brown  in  color,  and  have  a  projection  from  each  end  which  is 
the  characteristic  point. 

4.  Ova  of  JJncinaria. — They  are  oval  in  shape,  not  bile- 
stained,  a  transparent  shell  and  a  protoplasm  usually  divided 
into  from  2  to  8  segments. 

5.  Ova  of  Tmnia  Saginata. — They  are  oval  in  shape, 
contain  booklets  in  their  protoplasm  and  a  shell  which  is  radi- 
ally striated, 

6.  Ova  of  Tcenia  Nana. — They  are  spherical,  have  a  thick 
shell,  which  is  usually  in  layers. 

7.  Ova  of  Bothriocephalus  Latus  (rare  in  this  country).— 
They  are  oval  in  shape,  brown  in  color,  and  have  an  operculum 
at  one  end. 


Intestinal  Contents.  63 

Intestinal  Parasites  Recognized  by  the  Parasite  Itself, 
Portions  of  a  Parasite,  or  Larvae. — 

Intestinal  Parasites  that  are  recognized  in  the  stool  by 
the  parasite  itself,  portions  of  a  parasite  or  larvge  are : 
Amoeba  coli  and  cercomonas  hominis  (protozoa),  segments  of 
the  different  types  of  tape  worms,  ascaris  lumbricoides, 
oxyuris  vermicularis,  uncinaria,  larva  of  strongyloides  intes- 
tinalis,  larvee  of  the  house  fly  and  trichina  spiralis  (rarely). 

1.  Amceha  Coli  (protozoon). — Secure  the  grayish  or  blood- 
streaked  particles  from  a  fresh  stool  passed  into  a  warm 
vessel  or  by  removal  with  a  rectal  tube.  Place  on  a  warm 
slide  and  immediately  examine  microscopically  for  their 
irregular  amoeboid  movements. 

2.  Cercomonas  Hominis  (protozoon). — This  organism  is 
occasionally  seen  in  fresh,  warm  stools,  and  if  examined  micro- 
scopically it  is  motile.  It  is  oval  in  shape  and  contains 
flagella  at  one  end.     It  is  of  no  pathological  significance. 

3.  Segments  of  Tape  Worms. — Small  segments  are  passed 
at  intervals  if  an  individual  is  infected  with  any  of  the 
types. 

4.  Ascaris  Lumht'icoides. — They  are  passed  occasionally 
and  as  round  worms  are  easily  recognized. 

5.  Oxyuris  Vermiculans. — Occasionally  found  in  the 
fgeces  and  about  the  anus  of  children. 

6.  Uncinaria. — Not  often  found  in  faeces.  Give  thymol, 
followed  by  magnesium  sulphate,  and  they  then  may  be  usu- 
ally found  in  an  infected  patient. 

7.  Strongyloides  IntestinaUs. — In  this  neither  the  para- 
site nor  ova  are  found  in  the  faeces,  but  the  ova  hatch  in  the 
intestines,  and  the  actively  motile  larvae  may  be  seen.  The 
stools  should  be  examined  microscopically  while  fresh  and 
warm. 

8.  Larvce  of  the  House  Fly. — The  ova  of  the  house  fly 
may  be  ingested,  and  these  hatch  in  the  intestines.  The  larva, 
or  maggots,  may  be  found  in  the  faces  as  a  result. 

9.  Trichina  Spiralis. — The  worm  itself  may  be  rarely 
found  in  the  faces,  but  the  diagnosis  is  best  made  by  the 
eosinophilia  and  the  encysted  larva  in  the  muscles. 


CHAPTER  IX. 
TUBERCULIN  DIAGNOSIS. 

This  is  employed  in  three  ways : 

1.  Koch's  subcutaneous  method. 

2.  Cutaneous  reaction  of  Von  Pirquet,  and  Moro  Oint- 
ment. 

3.  Ophthalmo  reaction  of  Calmette. 

Tuberculin  is  made  by  growing  for  4  to  6  weeks  a  pure 
culture  of  bacillus  tuberculous  in  5  per  cent  glycerine 
bouillon.  This  is  filtered,  and  the  filtrate  evaporated  to  1/10 
of  its  volume.    This  resultant  fluid  is  known  as  the  tuberculin. 

Koch's  Subcutaneous  Method. 

This  is  given  subcutaneously  in  the  back  below  the  angle 
of  the  scapula.  Ordinarily  for  the  first  injection  0.2  m.  gm. 
is  given ;  if  no  evidence  of  a  reaction  in  2  or  3  days  a  second 
injection  of  1  m.  gm.  is  given ;  in  2  or  3  days  more  5  m.  gms. 
are  given,  and  finally  10  m.  gms.  Physiological  salt  solution 
is  used  as  the  diluting  fluid. 

The  chief  evidence  of  a  positive  reaction  is  fever,  at  least 
.5°  C.  or  more.  Other  less  important  signs  are:  headache, 
malaise,  insomnia,  and  nausea.  A  focal  reaction  may  occur 
at  the  location  of  the  tuberculous  lesion.  A  local  reaction 
may  take  place  at  the  point  of  injection. 

Indications  for  Use  of  this  Method. — 

In  adults  with  clinical  symptoms,  or  clinically  suspicious 
symptoms  of  tuberculosis,  but  who  are  devoid  of  the  pres- 
ence of  tubercle  bacilli  and  temperature. 

Contra-Indications. — 

Fever,   haemoptysis,   h^ematuria,   marked   cardiac  or  renal 
affection,  arteriosclerosis,  and  diabetes.     The  patient  should 
(64) 


Tuberculin  Diagnosis.  65 

be  placed  in  bed  2  or  3  days  before  the  injection  and  tem- 
perature taken  every  3  hours  to  be  certain  no  fever  is  present. 
The  patient  should  be  kept  in  bed  for  2  or  3  days  following- 
each  injection. 

Diag-nostic  Value. — 

A  negative  reaction  following  injection  of  5  m.  gms.  is  a 
very  strong  point  against  the  presence  of  a  tuberculous 
lesion  in  the  body.  A  positive  reaction  indicates  the  pres- 
ence of  a  tuberculous  lesion,  but  whether  it  is  an  active  pro- 
gressive one  or  a  latent  lesion  is  difficult  to  say. 

Von  Pirquet  Cutaneous  Reaction. 

Cleanse  the  patient's  forearm  on  the  inner  surface  Avith 
ether.  Place  two  drops  of  undiluted  tuberculin  upon  the 
skin  10  cm.  apart.  Scarify  the  skin  first  between  the  drops 
as  a  control,  and  then  scarify  within  the  two  drops.  ■  Place 
on  a  piece  of  cotton  for  about  10  minutes. 

Interpretation  of  Reaction. — 

Scarification  of  itself  produces  the  so-called  "traumatic 
reaction,"  i.  e.,  a  small  wheal  with  rose  colored  margin. 
This  passes  away  after  several  hours.  The  "specific  reaction" 
is  noticed  upon  the  upper  and  lower  points  where  the  tuber- 
culin has  been  applied  and  consists  of  a  red  indurated  papule, 
which  often  extends  in  size  10  to  30  m.m.  in  diameter.  This 
occurs  within  24  hours. 

Diagnostic  Value. — 

In  adults  it  is  void  of  any  diagnostic  value,  as  70  per  cent 
of  all  adults  give  a  positive  reaction.  Between  the  ages  of 
10  and  15  about  50  per  cent  of  all  cases  react  positively.  It 
is  of  some  value  in  children  less  than  10  years  of  age,  and 
of  very  considerable  value  in  children  younger  than  5  years. 

Moro  Ointment  Reaction. 

A  quantity  of  50  per  cent  ointment  of  tuberculin  about 
the  size  of  a  pea  is  warmed  lo  25°  C,  and  this  is  rubbed  into 
the  skin  of  the  abdomen  for  about  one  minute.    A  papule  or 


66  Diagnostic  Methods. 

small  nodular  eruption  occurring  within  24  or  36  hours  is 
regarded  as  positive.  The  diagnostic  value  is  variously  inter- 
preted;, and  it  possesses  in  this  respect  about  the  same  value 
as  Von  Pirquet's  reaction. 

Ophthalmo  Reaction  of  Calmette. 

For  this  a  one  per  cent  fresh  dilution  of  tuberculin  in 
physiological  salt  solution  is  made.  Place  one  drop  of  diluted 
tuberculin  in  the  inner  angle  of  the  eye  and  let  it  run  on  the 
inner  surface  of  the  lower  lid.  In  24  hours,  if  mucosa  of 
the  lower  lid  is  red  and  infected,  the  test  is  positive.  This 
test  is  of  particular  value  in  all  suspicious  cases  of  tubercu- 
losis where  the  presence  of  bacilli  can  not  be  demonstrated, 
and  the  subcutaneous  reaction  can  not  be  undertaken  on  ac- 
count of  the  presence  of  fever.  It  is  used  often  in  Vienna  on 
ambulatory  patients  without  any  bad  results  whatsoever. 

Oontra-Indications. — 

It  is  contra-indicated  in  all  diseases  of  the  eye,  tubercu- 
lous or  otherwise.  In  case  a  second  instillation  is  to  be 
given  the  other  eye  should  be  used.  This  is  sometimes  done 
when  there  is  no  reaction  with  a  one  per  cent  solution.  In 
this  instance  a  two  per  cent  or  even  three  per  cent  may 
be  used. 

Diagnostic  Value. — 

A  positive  reaction  indicates  in  about  80  per  cent  of  the 
cases  the  presence  of  tuberculosis,  but  as  to  whether  the 
tubercular  condition  is  active  or  latent  it  is  impossible  to  say. 


CHAPTER  X. 

THE  WASSERMANN  REACTION. 

Preliminary  preparation  and  tests  for  the  Wassermann 
reaction  are: 

1.  Preparation  and  standardization  of  the  amboceptor. 

2.  Preparation  and  standardization  of  the  antigen. 

3.  Obtaining  and  preparation  of  the  complement. 

4.  Obtaining  and  preparation  of  control  and  suspected 
sera. 

5.  Preparation  of  diluting  fluid. 

6.  Obtaining  and  washing  sheep's  red  blood  cells. 

Preparation  of  Amboceptor. — 

Inject  into  the  peritoneal  cavity  of  a  large  rabbit  gradually 
increasing  quantities  of  washed  sheep's  red  blood  cells  sus- 
pended in  0.8  per  cent  salt  solution.  Inject  the  first  time 
2  to  3  c.c.  of  the  cells,  in  four  days  3  to  4  c.c,  in  four  days 
again  4  to  5  c.c,  etc.  About  five  or  six  injections  are 
required.  Five  or  six  days  after  the  last  injection  administer 
a  little  ether  to  the  rabbit  and  dissect  out  the  carotid  artery, 
and  collect  the  blood  in  two  50  c.c.  graduates.  Place  on  ice, 
and  when  the  serum  has  separated,  draw  the  serum  off  and 
place  in  5  c.c.  quantities  in  small  size  test  tubes.  The  entire 
procedure  must  be  carried  out  in  a  sterile  manner.  Place  the 
test  tubes  containing  the  serum  in  a  water  bath  at  a  tempera- 
ture of  56  degrees  Centigrade,  and  maintain  this  for  30 
minutes.  This  inactivates  the  serum,  i.  e.,  destroys,  the  com- 
plement. 

Standardization  of  the  Amboceptor. — 

Have  six  test  tubes  of  about  10  c.c.  capacity  in  a  row,  and 
number  same  reading  from  left  to  right  as  follows:  I,  II, 
III,  IV,  V,  VI.  Test  tube  I  should  have  a  capacity  of  at 
least  15  c.c.     In  test  tube  I  place  0.1  c.c.  of  the  amboceptor, 

(67) 


68  Diagnostic  Methods. 

then  0.9  c.c.  of  0.8  per  cent  salt  solution,  and  9  c.e.  of  0.8  per 
cent  salt  solution.  This  gives  a  dilution  of  1  to  100.  Carry  1  c.c. 
from  this  and  place  in  test  tube  II,  then  add  1  c.c.  of  0.8  per 
cent  salt  solution.  Mix  well.  This  gives  a  dilution  of  1  to  200. 
Carry  1  c.c.  from  tube  II  to  tube  III  and  add  1  c.c.  of  0.8  per 
cent  salt  solution.  This  gives  a  dilution  of  1  to  400.  Continue 
this  process  to  tubes  IV,  V,  and  VI,  which  will  give  a  dilu- 
tion of  1  to  800,  1  to  1,600,  and  1  to  3,200  respectively.  Throw 
away  1  c.c.  from  the  last  tube.  Now  add  2  c.c.  of  0.8  per 
cent  salt  solution  to  tubes  II,  III,  IV,  V,  and  VI;  then  add 
to  same  tubes  1  c.c.  of  complement,  diluted  1  to  10  with  0.8 
per  cent  salt  solution.  To  the  same  tubes  now  add  1  c.c.  of 
5  per  cent  sheep's  red  blood  cells  in  0.8  per  cent  salt  solution. 
Place  in  the  incubator  at  371/2  degrees  Centigrade  for  30 
minutes  and  note  the  extent  of  complete  hgemolysis,  using  a 
dilution  of  the  amboceptor  between  this  dilution  and  the 
dilution  in  the  pre\aous  tube.  For  example,  if  haemolysis  is 
complete  in  the  1  to  800  dilution  and  not  present  in  the  1  to 
1,600  dilution,  then  the  strength  to  use  is  1  to  600.  This  is  the 
dilution  to  be  used  in  the  Wassermann  test,  and  1  c.c.  is  the 
quantity  used. 

Preparation  of  the  Antigen. — 

Get  a  fresh  heart  from  a  healthy  beef.  Remove  endocar- 
dium and  epicardium.  From  heart  muscle  scrape  off  30 
gms.  and  place  this  in  270  gms.  (by  weight)  of  95  per  cent 
alcohol.  Shake  as  often  as  possible  for  24  hours  and  keep 
at  room  temperature.  Then  filter  this  through  ordinary 
filter  paper.  This  filtrate  contains  the  antigen  to  be  used  in 
the  test. 

Standardization  of  the  Antigen. — 

HaA^e  six  test  tubes  of  about  10  c.e.  capacity,  and  number 
these  I,  II,  III,  IV,  V,  and  VI.  In  tube  I  place  0.1  c.c.  of 
antigen,  in  tube  II  place  0.2  c.c.  of  antigen,  in  tube  III  place 
0.3  c.c.  of  antigen,  0.4  c.c.  in  tube  IV,  0.5  c.c.  in  tube  V,  and 
0.6  c.c.  in  tube  VI.  Add  to  each  tube  2  c.c.  of  0.8  per  cent 
salt  solution.  Then  add  1  c.c.  of  the  diluted  amboceptor, 
usually  1  to  500,  or  1  to  600  dilution,  and  next  1  c.e.  of 


The  Wassermann  Reaction,  69 

complement  diluted  1  to  10  with  0.8  per  cent  solution,  and 
finally  to  each  tube  1  c.c.  of  5  per  cent  sheep's  red  blood 
cells.  Shake  well.  Place  in  incubator  at  37^^  degrees  cen- 
tigrade for  one-half  hour.  Examine  to  see  what  strength 
of  antigen  was  inhibitive  to  haemolysis.  Usually  0.15  c.c. 
and  0.2  c.c.  of  antigen  is  used,  as  this  is  found  practically 
always  to  be  noninhibitory  to  hemolysis. 

Obtaining  the  Complement. — 

This  is  done  by  removing  all  the  hairs  from  the  under 
surface  of  the  neck  of  a  guinea-pig,  and  with  scissors  sever- 
ing the  vessels  in  the  neck  and  catching  the  blood  in  a  petri 
dish.  A  better  method  is  to  dissect  out  the  carotid  artery, 
and  bleed  into  several  test  tubes.  This  blood  is  placed  in 
ice  chest,  and  the  serum  allowed  to  separate  off.  This 
serum  is  pipetted  off  and  placed  in  test  tubes.  It  may  be 
necessary  to  centrifugalize  to  separate  off  all  the  serum. 

Preparation  of  the  Complement. — 

Dilute  the  complement  in  the  proportion  of  1  c.c.  of 
guinea-pig's  serum  to  10  c.c.  of  0.8  per  cent  salt  solution. 
The  complement  should  ahvays  be  fresh. 

Obtaining  of  Patient's  Sera  for  Test. — 

Cleanse  well  the  arm  at  the  beud  of  the  elbow,  insert  a 
needle  into  a  prominent  vein,  and  allow  4  or  5  c.c.  of  blood 
to  pass  into  a  test  tube.  Place  in  ice  chest  and  allow  the 
serum  to  separate.  Place  this  at  once  into  another  test 
tube  and  inactivate  by  placing  in  a  warm  water  bath  at  56 
degrees  centigrade  for  30  minutes.  All  this  work  should 
be  done  in  a  sterile  manner. 

Diluting  Fluid. — 

This  fluid  is  0.8  per  cent  salt  solution.  Use  C.  P.  sodium 
chloride  dissolved  in  distilled  water. 

Obtaining  and  Washing  Sheep  Red  Blood  Cells. — 

Sheep  red  blood  cells  are  obtained  and  washed  in  the 
following  manner : 


70  Diagnostic  Methods. 

Clip  wool  from  the  neck  of  sheep  in  the  region  of  jugu- 
lar vein.  Shave  this  area.  Place  a  cord  about  neck  of 
sheep  directly  in  front  of  front  legs  and  tighten  same  so  as 
to  distend  the  veins.  With  a  needle  5  or  6  centimeters  long 
pass  into  vein  and  allow  the  blood  (10  or  15  c.c.)  to  pass 
into  a  wide  mouth  bottle  containing  about  15  c.c.  of  1  per 
cent  sodium  citrate  solution  in  0.8  per  cent  sodium  chlo- 
ride solution  and  a  dozen  glass  pearls.  Shake  gently  for 
several  minutes.  This  is  to  prevent  any  clotting.  Place  in 
centrifugal  tubes  and  centrifugalize  about  8  minutes.  With 
pipette  draw  off  the  supernatant  salt  and  citrate  solution. 
Pour  in  equal  quantity  of  0.8  per  cent  sodium  chloride  solu- 
tion. Mix  well  with  pipette.  Repeat  this  process  a  second 
and  a  third  time.  The  cells  are  now  washed  red  blood  celk. 
After  the  third  washing  add  same  amount  0.8  per  cent  salt 
solution  as  the  red  blood  cells ;  this  is  the  approximate 
quantity  of  blood  serum.  Two  or  three  c.c.  of  this  sus- 
pended in  a  little  0.8  per  cent  salt  solution  is  used  for  the 
first  injection  into  the  rabbit.  A  5  per  cent  solution  is 
used  in  the  standardization  of  the  antigen  and  amboceptor, 
and  also  in  the  Wassermann  test  itself. 

Technique  of  the  Wassermann  Test. 

Have  a  front,  middle  and  rear  test  tube  for  each  serum  to 
be  tested,  also  for  positive  control,  negative  control,  and 
antigen  control.  In  the  front  tube  place  0.6  c.c.  of  the 
serum,  then  add  to  this  2.4  c.c.  of  0.8  per  cent  sodium 
chloride  solution.  i\Iix  well  and  then  place  1  c.c.  of  this 
in  the  middle  tube  and  also  in  the  rear  tube.  This  gives 
0.2  c.c.  of  serum  in  each  tube.  Treat  all  the  sera  to  be 
tested,  and  also  positive  and  negative  control,  in  this  man- 
ner. In  the  antigen  control  tube  place  1  c.c.  of  0.8  per  cent 
salt  solution  in  front,  middle  and  rear  tubes. 

In  all  of  the  tubes  of  the  front  row  place  1  c.c.  of  10  per 
cent  complement,  also  0.15  c.c.  of  antigen,  0.85  c.c.  of  0.8 
per  cent  salt  solution. 

In  all  of  the  tubes  of  the  middle  row  place  1  c.c.  of  10^ 
per  cent  complement,  also  0.2  c.c.  of  antigen,  and  0.8  c.c. 
of  0.8  per  cent  salt  solution. 


The  Wasserniann  Reaction.  71 

In  all  of  the  tubes  of  the  rear  row  place  1  c.c.  of  10  per 
cent  complement  and  1  c.c.  of  0.8  per  cent  salt  solution,  but 
no  antigen. 

Shake  well.  Then  place  all  the  tubes  in  the  incubator  at 
37  degrees  centigrade  for  one  hour.  In  this  time  union  be- 
tween the  antigen  and  syphilitic  antibody  ( ?)  will  have 
taken  place  in  case  the  patient  has  syphilis,  and  so  doing, 
fixes  the  complement. 

In  one  hour  this  is  removed  from  the  incubator  and  1  c.c. 
of  the  1  to  500  (usually  thereabo.uts)  dilution  of  the  ambo- 
ceptor is  added  to  every  tube,  and  also  1  c.c.  of  the  5  per 
cent  suspension  of  the  red  blood  cells.  The  antigen  quan- 
tity in  the  antigen  control  tubes  is  doubled.  This  is  shaken 
well,  returned  to  the  incubator  for  no  longer  than  30  min- 
utes, or  until  the  controls  come  out  properly. 

Interpretation. — 

Hsemolysis  should  occur  in  the  negative  control  tubes, 
also  in  the  three  antigen  control  tubes.  The  rear  row  of 
tubes  should  show  haemolysis.  If  any  one  of  these  fail 
to  do  so,  the  test  on  that  serum  should  not  be  reported,  bat 
must  be  repeated.  Positive  control  tubes  should  show  the 
complete  absence  of  hemolysis.  All  the  sera  in  which  the 
two  front  tubes  show  the  absence  of  haemolysis  are  positive. 
All  the  sera  showing  complete  hgemolysis  are  negative.  The 
extent  of  the  inhibition  of  hgemolysis  varies  from  slight  in- 
hibition to  complete  inhibition.  Therefore  Ave  say  the  Was- 
sermann  test  is  weekly  positive,  positive,  or  strongly  posi- 
tive, this  being  indicated  by  a  single  plus  (-|-),  a  double 
plus   (-| — |-),  or  a  triple  plus   (-| — | — |-),  respectively. 


CHAPTER    XI. 
COMPLEMENT  FIXATION  TEST  FOR  GONORRHEA. 

In  this  test  the  haemolytic  system  is  used  as  in  the  "Was- 
sermann  reaction.  The  amboceptor  is  prepared  and  stand- 
ardized exactly  as  in  the  Wassermann  test.  The  comple- 
ment is  also  obtained  and  prepared  in  the  same  manner,  as 
is  also  the  control  and  suspected  sera.  The  sheep  red  blood 
cells  are  obtained  and  prepared  exactly  as  in  the  "Wasser- 
mann test.  The  antigen  used  by  the  author  at  the  pres- 
ent time  is  that  prepared  by  Parke,  Davis  &  Company. 

The  test  is  as  follows : 

Have  two  rows  of  test  tubes — a  front  row  and  a  back 
row.  In  each  tube  of  the  front  row  place;  the  following: 
1  drop  of  undiluted  antigen,  17  drops  of  0.8  per  cent  salt 
solution,  and  10  drops  of  complement  diluted  1  to  10.  In 
each  tube  of  the  rear  row  place  the  following :  18  drops  of 
0.8  per  cent  salt  solution,  10  drops  of  complement  diluted 
1  to  10.  Finally  place  in  a  front  tube  and  the  correspond- 
ing rear  tube  2  drops  of  inactivated  patient's  serum.  Re- 
peat this  in  other  tubes  with  inactivated  positive  serum, 
and  also  with  inactivated  negative  serum. 

This  should  be  placed  in  the  incubator  at  3714  degrees 
centigrade  for  30  minutes.  Remove  from  incubator  and 
place  in  each  front  tube  10  drops  of  the  diluted  amboceptor, 
the  unit  of  Avhich  has  been  determined  according  to  the 
method  given  in  the  Wassermann  reaction,  and  10  drops  of 
5  per  cent  Avashed  sheep  corpuscles.  In  each  rear  tube  place 
also :  10  drops  of  diluted  amboceptor  and  10  drops  of  5  per 
cent  sheep  corpuscles. 

Place  in  the  incubator  at  37^2  degrees  centigrade  and  in- 
cubate until  controls  come  out  properly,  i.  e.,  all  rear  tubes 
should  show  complete  htemolysis.  The  front  tube  of  the 
(72) 


Test  for  Gonorrhea.  73 

positive  control  should  show  the  absence  of  hsemolysis.  The 
front  tube  of  the  negative  control  should  show  hgemolysis. 
Therefore,  any  sera  showing  the  lack  of  hasmolysis  is  re- 
garded as  positive,  any  showing  the  presence  of  haemolysis 
is  regarded  as  negative. 


CHAPTER   XII. 

APPARATUS  AND  CHEMICAL  REAGENTS  NECESSARY 
FOR  A  PHYSICIAN'S  LABORATORY. 

Apparatus  Necessary. 

Microscope,  with  oil  immersion,  two-thirds  and  one-sixth 
objective;  Centrifugal  machine;  Blood  counter;  Tallquist's 
haemoglobin  scale ;  CoA^er  glasses  and  slides ;  Burette ;  For- 
ceps ;  Graduate ;  Specific  gravity  bulb ;  Doremus-Hinds 
urea  apparatus;  Test  tubes;  Red  and  blue  litmus;  Congo 
paper ;  Beakers ;  Flasks ;  Blood  lancet ;  Filter  stand ;  Es- 
bacli's  tube;  Funnels;  Stomach  tube;  Pipettes;  "Water  bath. 

Chemical  Reagents  Needed. 

Concentrated  nitric  acid;  Concentrated  sulphuric  acid; 
Concentrated  hydrochloric  acid ;  Glacial  acetic  acid ;  50  per 
cent  acetic  acid;  25  per  cent  acetic  acid;  .5  per  cent  sodium 
nitrate ;  10  per  cent  ammonium  hydrate ;  Decinormal  sodi- 
um hydrate ;  10  per  cent  sodium  hydrate ;  Sodium  nitro- 
prusside  crystals ;  Aqueous  solution  of  ferric  chloride ;  Io- 
dine solution  (tincture  iodine  1  part  and  alcohol  15  parts'*  ; 
20  per  cent  lead  acetate  solution;  Saturated  sodium  chlo- 
ride solution ;  Saturated  corrosive  sublimate  solution ;  Con- 
centrated hydrochloric  acid  with  .4  gm.  of  ferric  chloride 
in  100  c.c. ;  Saturated  aqueous  solution  of  Bismarck  brown; 
Wright's  blood  stain;  Absolute  alcohol;  95  per  cent  al- 
cohol; Ether;  Chloroform;  Loffler's  methylene  blue;  Gum 
guaiac ;  Tincture  iodine  ;  Hydrogen  peroxide ;  Saturated 
aqueous  solution  of  methylene  blue;  Topfer's  reagent  (di- 
methyl-amido-ozo-benzol  .5  per  cent  in  80  per  cent  alcohol)  ; 
Gunzburg's  reagent  (phloroglucin  2  gms.,  vanillin  1  gm.,  95 
per  cent  alcohol  30  c.c.)  ;  Carbol-fuchsin  (carbolic  acid  5  c.c., 
saturated  alcoholic  solution  of  fuchsin  10  c.c),  and  distilled 
(74) 


Apparatus  and  Reagents  Necessary  for  Laboratory.      75 

water  100  c.c.)  ;5  per  cent  copper  sulphate  solution ;  Strong 
sodium  hydrate  solution;  10  per  cent  copper  sulphate  solu- 
tion; 5  per  cent  ammonium  iron  alum  solution;  10  per  cent 
ammonium  hydrate  solution;  Saturated  potassium  oxalate 
solution;  10  per  cent  aqueous  solution  ferric  chloride;  Ani- 
line oil;  Saturated  alcoholic  solution  of  gentian  violet;  5 
per  cent  aqueous  solution  of  carbolic  acid;  Crystals  of  so- 
dium iodide;  Infusorial  earth;  4  per  cent  solution  of  glacial 
acetic  acid  tinged  with  little  gentian  violet;  10  per  cent 
butyric  acid  solution  in  normal  saline ;  Normal  sodium 
hydroxide  solution;  10  per  cent  potassium  f errocyanide ; 
Red  litmus  paper;  Blue  litmus  paper. 

FehUng's  Solution. — Dissolve  34.64  gms.  of  pure  copper 
sulphate  in  water  and  make  up  to  500  c.c.  Dissolve  173  gms. 
of  E-ochelle  salts  and  125  gms.  of  sodium  hydrate  each  in  200 
c.c.  of  water.  Mix  and  make  also  to  500  c.c.  Keep  copper 
solution  and  alkaline  solution  in  two  separate  bottles. 

Sulphamlic  Acid. — Make  a  saturated  solution  of  sulpha- 
nilic  acid  in  a  5  per  cent  hydrochloric  acid  solution.  This 
is  for  the  Diazo  reaction. 

Bromine  Solution  (For  Urea). — Bromine  30  c.c,  potas- 
sium bromide  30  gms.,  and  distilled  water  240  c.c. 

Sodium  Hydrate  Solution  {For  Urea). — Sodium  hydrate 
10  gms.,  distilled  water  250  c.c. 

Hayem's  Solution. — Mercuric  chloride  0.5  gms.,  sodium 
chloride  1  gm.,  sodium  sulphate  5  gms.,  distilled  water  200  c.c. 

Gram's  Iodine  Solution. — Iodine  1.0  gm.,  potassium  iodide 
2.0  gms.,  distilled  water  800  c.c. 

Eshach's  Reagent. — Picric  acid  1.0  gm.,  Citric  acid  2  gms., 
water  100  c.c, 

Phenylhydrazine  Acetate  Solution. — 20  per  cent  aqueous 
solution  of  sodium  acetate  25  c.c,  10  per  cent  aqueous  solu- 
tion of  phenylhydrazine  hydrochloride  25  c.c.     Mix. 

Nylander's  Reagent. — Bismuth  subnitrate  gms.  2,  Rochelle 
salts  4  gms.,  8  per  cent  sodium  hydrate  solution  100  c.c 

Standard  Silver  Nitrate  Solution. — 7.27  gms.  to  250  c.c  of 
distilled  water.  1  c.c.  of  this  equals  10  M.  gms.  of  sodium 
chloride. 


76  Diagnostic  Methods. 

Standard  Ammonium  Sulphocyanat  Solution. — 3.25  gms. 
to  250  c.c.  distilled  water.  1  c.c.  of  this  equals  1  c.c.  of  the 
silver  nitrate  solution. 

Tsuchiya's  Reagent. — Phosphotungstic  acid  1.5  gm.,  con- 
centrated hydrochloric  acid  5.0  c.c,  95  per  cent  alcohol  95  c.c. 

Acid  Alcohol.' — 1^/2  c.  c.  of  concentrated  hydrochloric  acid, 
981/2  c.c.  of  95  per  cent  alcohol. 

Rudisch  Solution  {For  Quantitative  Glucose). — 200  c.c.  of 
50  per  cent  aqueous  solution  of  potassium  sulphocyanate, 
and  150  c.c.  of  a  mixture  of  equal  parts  of  Fehling's  copper 
sulphate  and  alkaline  solutions. 


INDEX 


A 

AcHTLiA  gastrica,  44 

Apparatus  necessary  for  physician's  laboratory,  74 

B 

Blood,  45-53 
culture,  51 

examination  of  fresh,  45 
haemoglobin,  45 
estimation  of,  45 

by  Sahli  hsemometer,  45 
by  Talquist  scale  of  colors,  45 
color  index,  46 
Widal's  serum  reaction,  50 
Blood  changes  in: 

acute  lymphatic  leukemia,  52 
chlorosis,  53 

chronic  lymphatic  leukemia,  53 
pernicious  anemia,  52 
splenomegaly  or  splenic  anemia,  53 
spleno-myelogenous  leukemia,  53 
Blood  counting,  46 

apparatus  for,  cleaning  of,  49 
chambers  for,  47 
red  corpuscles,  48 
white  corpuscles,  49 
Blood  smear,  making  of,  46 
method  of  staining,  49 

C 

Complement  fixation  test  for  gonorrhea,  72-73 
Chemical  reagents  needed  for  laboratory,  74-76 


78  Index. 


Examination  of: 
alimentary  canal,  13 
cardiovascular  system,  14 
cranial  nerves,  15 
ears,  18 
eyes,  17 

elastic  fibers,  22 
larynx,  18 

locomotor  system,  17 
motor  functions,  16 
nervous  system,  15 
nose,  18 
reflexes,  17 

respiratory  system,  14 
sensory  functions,  16 
sputum,  19 
urine,  25 


Gastric  cancer,  43 
Gastric  contents,  38-44 
chemical  examination  for: 

blood,  41 

combined  hydrochloric  acid,  39 

free  acids,  39 

free  hydrochloric  acid,  39 

organic  acids,  40 

pepsin,  40 

rennin,  40 
in  disease,  43 

microscopical  examination,  43 
physical  examination,  38 

color,  39 

mucous,  39 

odor,  39 

quantity,  38 
quantitative  examination  for: 

combined  hydrochloric  acid,  42 
■  free  hydrochloric  acid,  41 

total  acidity,  42 
test  meal,  38 


Index.  79 


Gastric  neurosis,  44 

ulcer,  43 
Gastritis,  chronic,  44 
Gram's  stain,  22 


H 


History  taking,  outline  for,  9-12 
History,  family,  9 
past,  10 
personal,  9 
of  present  illness,  10 
alimentary  canal,  10 
blood,  12 

bones  and  joints,  12 
cardiovascular  system,  11 
child,  12 
kidneys,  11 
liver,  11 

nervous  system,  12 
respiratory  system,  11 


IntestiA'AL  contents,  58-63 
chemical  examination  of,  60 

bile  (hydro-bilirubin),  60 

blood  (occult),  60 
macroscopic  examination  of,  58 

blood,  59 

color,  58 

consistency,  59 

curds,  59 

frequency,  58 

mucus,  59 

odor,  59 

pus,  59 

quantity,  58 
microscopical  examination  of,  61 

bacteria,  61 

blood  cells,  61 

epithelial  cells,  61 

food  particles,  61 


80  Index. 

ova  of  intestinal  parasites,  62 
pus  cells,  61 
stools,  examination  of,  58 
Intestinal  parasites  recognized  by  the  parasite  itself,  portions  of  the 
parasite,  or  larvK,  63 


S 


Serous  fluids,  54-57 

bacteria  in,  55 

chemical  examination,  54 

cytodiagnosis,54 

lumbar  puncture,  technique  for,  56 

Noguchi's  butyric  acid  test,  56 

physical  examination,  54 

total  cell  count  of,  55 
Sputum,  19-24 

bacillus  tuberculosis,  staining  of,  21 

color  of,  20 

elastic  fibers,  examination  for,  22 

examination  of,  19 

hemorrhagic,  20 

macroscopic  examination,  19 

microscopic  examination,  20 

mucous  or  viscid,  19 

mucopurulent,  19 

nummular,  20 

odor,  19 

origin,  19 

pneumococcus,  staining  of,  21 

purulent,  19 

quantity,  19 

serous,  19 

tenacious,  20 

Sputum  in  bronchiectasis,  24 
in  bronchitis,  24 
in  bronchial  asthma,  24 
in  pneumonia,  23 
in  tuberculosis,  23 


TuBERcuLix  diagnosis,  64-66 
Koch's  subcutaneous  method,  64 
contra-indications,  64 


Index.  81 


diagnostic  value,  65 

indications  for  use  of,  64 
Moro  ointment  reaction,  64 
Ophtlialmo  reaction  of  Calmette,  66 

contra-indications,  66 

diagnostic  value,  66 
Von  Pirquet  cutaneous  reaction,  65 

diagnostic  value,  65 

interpretation  of,  65 

U 

Urixe.  25-37 

acute  diffuse  nephritis,  35 
arteriosclerotic  kidney,  37 
bacillus  tuberculosis  in,  examination  for,  34 
chemical  examination: 

acetic  acid  and  ferrocyanide  test  for  albumen,  26 

acetone,  29 

albumen,  tests  for,  26 

albumose,  27 

beta-oxybutyric,  29 

bile,  27 

diacetic  acid,  29 

dlazo  substances,  29 

indican,  28 

nucleo-albumen,  27 

haemoglobin,  27 

serum-albumen,  26 

serum-globulin,  27 

sugar,  28 
chronic  diffuse  nephritis,  35 
chronic  interstitial  nephritis,  36 
preservation  of,  25 
quantitative  examination  of  abnormal  constituents,  2,1 

albumen,  31 

Indican,  32 

sugar,  33 
quantitative  examination  of  normal  constituents,  30 

chlorides,  30 

total  acidity,  31 

total  solids,  31 

urea,  30 


82  Index. 

renal  tuberculosis,  36 

sediment  in,  microscopical  examination  of, 

turbidity  of,  25 

W 

Wasserman>'  reaction,  67-71 
amboceptor,  preparation,  67 

standardization,  67 
antigen,  preparation,  68 

standardization,  68 
complement,  obtaining,  69 

preparation,  69 
diluting  fluid,  69 
patient's  sera  for  test,  69 
sheep's  red  blood  cells,  69 
Wassermann  test,  technique  of,  70 
interpretation,  71 


The  Mosby  Company's  New  Books  on  Diagnosis 


LABORATORY  METHODS 

With  Special  Reference  to  the  Needs  of  the  General  Practitioner 

By   B.   G.    R.  WILLIAMS,   M.   D., 

Member  of  Illinois  State  Medical  Society,  American  Medical  Associatioiij,  Etc. 

Assisted   by    E.   G.   C.   WILLIAMS,    M.    D., 

Formerb'    Pathologist    of   Northern   Michigan    Hospital    for    the    Insane, 
Traverse   City,   Michigan,   Etc. 

With   an  Introduction  by 

VICTOR    C.    VAUGHAN,    M.    D.,    LL.D., 

Professor  nf  Hygiene  and  Physiological  Chemistry  and  Dean  of  the  Department   of 

Medicine  and  Surgery,   I'niversity  of  Michigan ;  President-Elect 

of  the  American  Medical  Association. 

SECOND    EDITION,    REVISED    AND    REWRITTEN. 

Octavo,   2.50   pages,   with   .50    engravings.   Cloth,    .$2.50 


CONTENTS 


Chapter 

I.     General  Considerations. 
II.     The   Sputum, 
in.     Searching  for  Germs. 
IV.     Vascular   Dramas. 
V.     Chemistry    and    Biology    of    the 

Gastric  Juice. 
VI.     Essence  of  Tissue  Diagnosis. 
VII.     Detection    of    the    Common    Poi- 
sons. 
VIII.     Exudates  in  Brief. 
IX.     Diazo  Versus  Widal. 
X.     The  Urine  in  Disease. 


Chapter 

XI.     Millv    and    Its    Home    Modifica- 
tions. 

XII.     Some  Simple  Water  Analyses. 

XIII.  Every-Day  Stool  Tests. 

XIV.  Technic    of    the    Private    Post- 

Mortem. 

XV.     To   Find  the   Treponema    in   Six 
Minutes. 

XVI.     Laboratory    Prophylaxis. 

XVII.     Indications  for  Laboratory  Aids. 

XVIII.     Tables   and   Miscellaneous. 


FROM    REVIEWS 

This  book  may  he  freely  commended  to  those  who  may  desire  a  working  guide  to 
the  more  usual  laboratory  methods.  The  stj'Ie  is  clear  and  concise,  and  the  general 
makeup  of  the  book  is  excellent. — .Journal   of  the  American  Medical  Association. 

General  practitioners  are  under  an  everlasting  debt  of  gratitude  to  the  Williamses 
for  their  textbook.  Any  publication  which  lightens  the  burdens  of  these  physicians 
and  points  out  a  way  to  bettering  their  work  is  bound  of  necessity  to  succeed. — 
Maryland  Medical  .Tournal. 

It  has  been  the  aim  of  the  authors  of  this  admirable  book  to  simplify  methods 
both  as  to  apparatus  and  technic,  and  we  can  testify  that  they  have  succeeded  most 
admirably  in  their  every  effort.  Every  general  practitioner  should  procure  a  copy  of 
this  book  and  study  it  carefully,  and  it  will  show  that  many  of  the  comparatively 
simple  cases  that  are  usually  sent  to  distant  cities  for  expert  examination  may  be 
made  with  more  satisfactory  results  by  the  practitioner  at  home. — The  Medical  Sum- 
mary. 


The  Mosby  Company' s  Neiv  Books  on  Diagnosis 


TUBERCULIN 

In  Diagnosis  and  Treatment 

By    FRANCIS    MARION    POTTENGER,    A.    M.,    M.    D.,    LL.D., 

Medical  Director  of  the  Pottenger  Sanatorium  for  Diseases  of  the  Lungs  and  Throat, 
Monrovia ,  California . 


Octavo,   250  pages,  with 


engravings  and   1   color  plate. 


Price,   Cloth,   $2.50. 

Tuberculin  is  a  great  therapeutic  remedy.  Since  its  first  introduction  b.v  Robert 
Koch  it  has  proved  of  inestimable  value  in  the  hands  of  the  skillful  phj'sician. 
The  occasional  bad  results  that  have  attended  its  use  have  been  due  more  to 
faulty  technique  than  to  the  remedy.  Doctor  Pottenger  has  authority  to  speak  on 
this  subject.  This  book  is  the  experience  he  has  gained  by  treating  more  than  two 
thousand   cases   in   private   sanitarium   practice. 


CONTENTS 


Chanter 


I.  Importance  of  the  Tuberculin 
Test  in  tlie  Early  Diagnosis 
of  Tuberculosis. 

II.     Subcutaneous     Tube  r  culin 
Test. 

III.  Cutaneous    Tuberculin    Test. 

IV.  Percutaneous     Tuber  culin 

Test. 

V.     Conjunctival  Tuberculin  Test. 

VI.     Tuberculin   in  the  Treatment 
of  Tuberculosis. 

VII.     Hypersensitiveness. 


Chapter 
VIII. 


X. 
XI. 
XII. 

Appendix. 


Certain  Conditions  Which 
Have  Made  the  Adoption  of 
Tuberculin  as  a  Diagnostic 
and  Therapeutic  Measure 
Difficult. 

Evidences  of  the  Therapeu- 
tic Value  of  Tuberculin. 

Fever  in  its  Relatiousliip  to 
Tuberculosis. 

Temperature  Curve  in  Tuber- 
culosis. 

Technic      of      Administering 

Tuberculin. 
Koch's  Announcement  of  the 

Discovery    of    Tuberculin/. 


FROM    REVIEWS 


This  book  by  Pottenger,  who  has  long  been  recognized  as  an  authority  on  every- 
thing pertaining  to  pulmonary  tuberculosis,  contains  about  everything  worth  knowing 
at  the  present  time  on  the  use  of  tuberculin  in  both  diagnosis  and  treatment.  It  is 
a  book  of  great  value  not  only  to  the  specialist,  but  also  to  the  general  practitioner. 
— .lournal  of  the  Michigan   State   Medical  Association. 

We  have  enjoyed  reading  this  work.  Dr.  Pottenger  has  the  reputation  of  being 
exceptionally  thorough  in  his  diagnostic  work  and  we  are  given  the  benefit  of  this  in 
the  book.  The  author  makes  it  plain  that  the  use  of  tuberculin  for  diagnostic  pur- 
poses is  corroborative  only,  that  to  in  any  measure  neglect  the  history  and  physical 
findings  invites  failure.  We  heartily  recommend  this  book  to  the  attention  of  gen- 
eral  practitioners. — Journal   of   the  Iowa   State   Medical   Association. 


The  Mosby  Company's  New  Books  on  Diagnosis 


THE  WASSERMANN  REACTION 

Its  Technic  and  Practical  Application  in  the  Diagnosis  of  Syphilis 

By  JOHN  W.   MARCHILDON,   B.  S.,   M.  D., 

Assistant  Professor   of  Bacteriology,   St.   Louis   rniversity   Medical   School, 
St.  Louis. 

105  pages,  with  11  illustrations  and  1  colored  frontispiece. 
Price,   Cloth,  $1.50. 


CONTENTS 


Chapter 

I.     ^Materials     Required    for     Making 
tlie    Wassermann    Reaction. 

II.  The  Preparation  of  the  Hem- 
olytic Amboceptor  or  Hemoly- 
sin. 

III.  The    Preparation    of    Complement. 

IV.  The    Preparation    of    Red    Blood 

Corpuscles. 

y.  The  Preparation  of  Serum  from 
the  Patient. 

\J.     The   Preparation    of   the   Antigen. 


Chapter 

VII.     To   Obtain  the  Dosage  of  an  Ex- 
tract. 
VIII.     The    Method    of    Making    a    Was- 
sermann Reaction. 
IX.     The   Modification   of   the   Wasser- 
mann Reaction. 
X.     The      Wassermann      Reaction     in 

Syphilis. 
XI.     The  Wassermann  Reaction  in  Dis- 
eases other  than   Syphilis. 
XII.     The     Influence     of    Anti-Sypilitic 
Treatment    on    the    Wassermann 
Reaction. 


FROM    REVIEWS 

We  can  commend  this  excellent  little  work  to  those  who  wish  to  become  more 
independent  of  the  larger  laboratories  and  to  place  themselves  in  a  position  better  to 
understand  and  perform  this  most  important  diagnostic  test. — Journal  American 
iledical  Association. 

This  volume  should  be  on  the  shelves  of  every  physician. — Interstate  Medical 
.Tonrnal. 

We  commend  the  work  to  those  of  our  readers  interested  (and  what  physician  is 
not)    in  the  accurate  diagnosis  of  syphilis. — The  American  Practitioner. 

This  little  volume,  big  enough,  sets  forth  In  clear  terms  the  technic  of  the  Wasser- 
mann reaction.  The  author  has  peeled  away  much  that  was  designed  to  befog  the 
man  of  limited  acquirements  in  the  laboratory,  thereby  enabling  the  man  of  patience 
and  average  ability  to  do  all  of  his  own  laboratory  work.  His  style  is  clear,  cogent 
and  apt  to  teach. — .lournal  of  the  Texas  State  Medical  Association. 

This  primer  of  the  Wassermann  reaction  can  be  recommended  as  a  very  clear  and 
concise  statement  of  the  rationale  and  technic  of  that  complicated  test. — American 
Journal  of  Surgery. 

This  book,  like  practically  all  emanating  from  this  house,  depends,  not  upon  the 
author  but  upon  what  he  knows,  not  upon  the  possibility  of  competing  in  already 
well  supplied  markets  by  ottering  staple  goods  bearing  a  name  that  it  is  hoped  will 
lure  purchasers  from  other  stalls,  but  upon  the  delivery  of  goods  not  elsewhere  on 
sale.     We  recommend  the  book  heartily. — Butfalo  Medical  Journal. 


The  Moshy  Company's  New  Books  on  Diagnosis 


VACCINE  AND  SERUM  THERAPY 

Including  also  a  Study  of  Infections,  Theories  of  Immunity,  Specific 
Diagnosis,  and  Chemotherapy 

By   EDWIN    HENRY  SCHORER, 

B.    S.    (University   of   Wisconsin),    il.    D.    (Jolius   Hopkins    University), 
Dr.  P.  H.    (Harvard  Univeristy). 

Formerly  Assistant  Thomas  Wilson  Sanitarium  for  Children,  Mt.  Wilson,  Maryland; 
Asst.  Rockefeller  Institute  for  ^Medical  Research,  Xew  York  City ;  and  at  one 
time  Member  of  the  Faculty  of  the  University  of  Missouri,   of  the 
University  of  Kansas,  and  of  the  Department  of  Preventive 
^Medicine    and   Hygiene   of  Harvard    Univer- 
sity, Boston. 

Octavo,  2.50  pages,  with  IS  engravinga  and  a  colored  plate. 

Price,    Cloth,   $3  00. 

SECOND   REVISED   EDITION. 


CONTENTS 

Chapter 

Chapt 

I. 

Infections. 

ir. 

Immunity. 

III. 

Specific   Diagnosis. 

IV. 

Specific   Therapy. 

. 

Appen 

Specific  Diagnosis,  Treat- 
ment and  Prophylaxis  In 
the  Different   Infections. 

Syphilis  and  Malaria. 


FROM    REVIEWS 


It  contains  all  that  is  necessary  for  physicians  to  know  about  this  new  and  fasci- 
nating method  of  treatment.  The  text  is  well  done  and  the  illustrations  are  adequate. 
Doctor  Schorer  has  had  a  large  and  varied  experience  and  is  the  master  of  the 
technique  of  the  laboratory. — The  Canadian  Medical  Association  Journal. 

The  whole  subject  has  been  treated  in  a  very  practical  and  comprehensive  manner, 
and  we  heartily  recommend  the  book  to  all  who  may  be  interested  in  the  subject. — 
Journal  of  the  Indiana   Medical  Association 

This  revised  second  edition  will  be  welcomed  by  all  interested  in  the  treatment  of 
disease,  medical  and  surgical.  Altogether  this  will  prove  a  valuable  addition  to  the 
literature  on  vaccine  and  seruui  therapy. — The  American   Practitioner. 

It  is  a  book  which  merits  careful  study  in  order  that  such  a  valuable  adjunct  as 
vaccine  therapy  may  not  be  either  over-rated  or  under-rated. — Journal  of  the  Iowa 
State  Medical  Society. 


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